Provider Demographics
NPI:1205233012
Name:SAINT VICENT'S DENTAL CENTER
Entity type:Organization
Organization Name:SAINT VICENT'S DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-757-5244
Mailing Address - Street 1:116 WATCHUNG AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-4822
Mailing Address - Country:US
Mailing Address - Phone:908-757-5244
Mailing Address - Fax:
Practice Address - Street 1:116 WATCHUNG AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-4822
Practice Address - Country:US
Practice Address - Phone:908-757-5244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02199800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8958700Medicaid