Provider Demographics
NPI:1710060496
Name:SURGERY CENTER OF PENTHOUSE IV
Entity Type:Organization
Organization Name:SURGERY CENTER OF PENTHOUSE IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:NIEBLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-736-7616
Mailing Address - Street 1:101 OLD SHORT HILLS ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-736-1345
Mailing Address - Fax:973-325-3487
Practice Address - Street 1:101 OLD SHORT HILLS ROAD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-736-1345
Practice Address - Fax:973-325-3487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty