Provider Demographics
NPI:1871644419
Name:FAMILY DENTAL ASSOCIATES OF BROOKDALE, L.L.C.
Entity Type:Organization
Organization Name:FAMILY DENTAL ASSOCIATES OF BROOKDALE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PANITCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-338-6667
Mailing Address - Street 1:988 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2806
Mailing Address - Country:US
Mailing Address - Phone:973-338-6667
Mailing Address - Fax:973-338-1856
Practice Address - Street 1:988 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2806
Practice Address - Country:US
Practice Address - Phone:973-338-6667
Practice Address - Fax:973-338-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ21896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ21896OtherDENTAL LICENSE NUMBER