Provider Demographics
NPI:1770779902
Name:PEQUANNOCK VALLEY DENTAL ASSOCIATES
Entity type:Organization
Organization Name:PEQUANNOCK VALLEY DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-831-0444
Mailing Address - Street 1:567 NEWARK POMPTON TPKE
Mailing Address - Street 2:
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444-1737
Mailing Address - Country:US
Mailing Address - Phone:973-831-0444
Mailing Address - Fax:973-831-7770
Practice Address - Street 1:567 NEWARK POMPTON TPKE
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1737
Practice Address - Country:US
Practice Address - Phone:973-831-0444
Practice Address - Fax:973-831-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022089001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty