Provider Demographics
NPI:1891806147
Name:MIDLAND FAMILY DENTAL CARE,PA
Entity Type:Organization
Organization Name:MIDLAND FAMILY DENTAL CARE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-340-4484
Mailing Address - Street 1:765 MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-2100
Mailing Address - Country:US
Mailing Address - Phone:973-340-4484
Mailing Address - Fax:973-340-2282
Practice Address - Street 1:765 MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026-2100
Practice Address - Country:US
Practice Address - Phone:973-340-4484
Practice Address - Fax:973-340-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ191621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty