Provider Demographics
NPI:1336772664
Name:DIVINE DENTAL LLC
Entity Type:Organization
Organization Name:DIVINE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-345-8881
Mailing Address - Street 1:485 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4313
Mailing Address - Country:US
Mailing Address - Phone:201-345-8881
Mailing Address - Fax:
Practice Address - Street 1:485 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4313
Practice Address - Country:US
Practice Address - Phone:201-345-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty