Provider Demographics
NPI:1992180376
Name:PARRA, MASSIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MASSIEL
Middle Name:
Last Name:PARRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 MAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-574-1000
Mailing Address - Fax:973-574-1001
Practice Address - Street 1:625 MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-574-1000
Practice Address - Fax:973-574-1001
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02607900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0491977Medicaid