Provider Demographics
NPI:1710962402
Name:MARCONYAK, LOUIS JOSEPH JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JOSEPH
Last Name:MARCONYAK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 MCGUIRE BLVD BLDG 2417
Mailing Address - Street 2:
Mailing Address - City:JB MDL
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5116
Mailing Address - Country:US
Mailing Address - Phone:609-754-3787
Mailing Address - Fax:609-754-9042
Practice Address - Street 1:2417 MCGUIRE BLVD BLDG 2417
Practice Address - Street 2:
Practice Address - City:JB MDL
Practice Address - State:NJ
Practice Address - Zip Code:08641-5116
Practice Address - Country:US
Practice Address - Phone:609-754-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411087122300000X
VA04014440871223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist