Provider Demographics
NPI:1184054645
Name:MODERN FAMILY DENTISTRY
Entity type:Organization
Organization Name:MODERN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:917-561-7256
Mailing Address - Street 1:551 JERSEY AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 JERSEY AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-2788
Practice Address - Country:US
Practice Address - Phone:917-561-7256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024543001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty