Provider Demographics
NPI:1760890750
Name:VITRUVIAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:VITRUVIAN DENTAL CORPORATION
Other - Org Name:VITRUVIAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SANG
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-527-7241
Mailing Address - Street 1:577 CHESTNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677-8409
Mailing Address - Country:US
Mailing Address - Phone:201-746-6003
Mailing Address - Fax:
Practice Address - Street 1:577 CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:WOODCLIFF LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07677-8409
Practice Address - Country:US
Practice Address - Phone:201-746-6003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ21228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty