Provider Demographics
NPI:1942223227
Name:FAKTOR, DEREK J (DMD MBA)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:J
Last Name:FAKTOR
Suffix:
Gender:M
Credentials:DMD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E 56TH ST APT 6D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-3744
Mailing Address - Country:US
Mailing Address - Phone:732-718-1063
Mailing Address - Fax:
Practice Address - Street 1:16 PLAZA 9
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3010
Practice Address - Country:US
Practice Address - Phone:732-431-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050923122300000X
NJDI0215201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice