Provider Demographics
NPI:1871666586
Name:HERAWATI T KANDOU DDS PA
Entity Type:Organization
Organization Name:HERAWATI T KANDOU DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HERAWATI
Authorized Official - Middle Name:T
Authorized Official - Last Name:KANDOU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-354-1188
Mailing Address - Street 1:35 JEFFERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2425
Mailing Address - Country:US
Mailing Address - Phone:908-354-1188
Mailing Address - Fax:908-352-7390
Practice Address - Street 1:35 JEFFERSON AVENUE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2425
Practice Address - Country:US
Practice Address - Phone:908-354-1188
Practice Address - Fax:908-352-7390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ9708122300000X
NJ30261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ314120901Medicaid