Provider Demographics
NPI:1821086901
Name:KALLIS, JOHN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:KALLIS
Suffix:
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 1:617 E PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-1831
Mailing Address - Country:US
Mailing Address - Phone:201-567-7500
Mailing Address - Fax:201-567-7505
Practice Address - Street 1:617 E PALISADE AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-1831
Practice Address - Country:US
Practice Address - Phone:201-567-7500
Practice Address - Fax:201-567-7505
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI154721223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1666908Medicaid
NJ1666908Medicaid