Provider Demographics
NPI:1760474753
Name:VARGHESE, MARY (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 GOLDEN POND DR
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-2181
Mailing Address - Country:US
Mailing Address - Phone:732-951-8089
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0460821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00665274Medicaid
NY00665274Medicaid
NYD48071Medicare ID - Type Unspecified