Provider Demographics
NPI:1356432173
Name:FRUCHTER, MICHAL R
Entity type:Individual
Prefix:
First Name:MICHAL
Middle Name:R
Last Name:FRUCHTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SOUTH PKWY
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07014-1244
Mailing Address - Country:US
Mailing Address - Phone:973-249-8107
Mailing Address - Fax:
Practice Address - Street 1:475 SOUTH PKWY
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07014-1244
Practice Address - Country:US
Practice Address - Phone:973-249-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO22873001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare ID - Type Unspecified