Provider Demographics
NPI:1982663639
Name:QD 775 UNION BLVD., LLC
Entity Type:Organization
Organization Name:QD 775 UNION BLVD., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SALVADOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-812-1234
Mailing Address - Street 1:775 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2207
Mailing Address - Country:US
Mailing Address - Phone:973-812-1234
Mailing Address - Fax:973-812-0679
Practice Address - Street 1:775 UNION BLVD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2207
Practice Address - Country:US
Practice Address - Phone:973-812-1234
Practice Address - Fax:973-812-0679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ161391223G0001X
NJ159341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty