Provider Demographics
NPI:1699188417
Name:WATCHUNG AVENUE DENTAL LLC
Entity Type:Organization
Organization Name:WATCHUNG AVENUE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER-MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-222-0007
Mailing Address - Street 1:445 WATCHUNG AVE
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-4956
Mailing Address - Country:US
Mailing Address - Phone:908-222-0007
Mailing Address - Fax:
Practice Address - Street 1:445 WATCHUNG AVE
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-4956
Practice Address - Country:US
Practice Address - Phone:908-222-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024141001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty