Provider Demographics
NPI:1710300702
Name:DENTAL MENTORS
Entity Type:Organization
Organization Name:DENTAL MENTORS
Other - Org Name:DENTAL SLEEP ALTERNATIVES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TALTAVALL
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-628-1449
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:166 MAIN STREET SUITE 1B
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-0457
Mailing Address - Country:US
Mailing Address - Phone:973-628-1449
Mailing Address - Fax:973-696-0037
Practice Address - Street 1:166 MAIN ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-3707
Practice Address - Country:US
Practice Address - Phone:973-628-1449
Practice Address - Fax:973-696-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI18340261QD0000X
NJDI18175261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7395710001Medicare NSC