Provider Demographics
NPI:1740424431
Name:CENTER FOR DENTISTRY AT HUMC, FACULTY PRACTICE LLC
Entity Type:Organization
Organization Name:CENTER FOR DENTISTRY AT HUMC, FACULTY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEALS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-996-2734
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1914
Mailing Address - Country:US
Mailing Address - Phone:201-996-2734
Mailing Address - Fax:201-996-2334
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:201-996-2734
Practice Address - Fax:201-996-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D101000301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty