Provider Demographics
NPI:1700365129
Name:MONDOVI DENTAL OF NEW JERSEY - BEJARANO PC
Entity Type:Organization
Organization Name:MONDOVI DENTAL OF NEW JERSEY - BEJARANO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRION-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-598-2311
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-0090
Mailing Address - Country:US
Mailing Address - Phone:715-598-2311
Mailing Address - Fax:715-350-6855
Practice Address - Street 1:513 BOULEVARD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1637
Practice Address - Country:US
Practice Address - Phone:908-276-6652
Practice Address - Fax:908-709-4337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty