Provider Demographics
NPI:1780940395
Name:1137 FORT LEE LLC
Entity type:Organization
Organization Name:1137 FORT LEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-224-8180
Mailing Address - Street 1:1625 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2748
Mailing Address - Country:US
Mailing Address - Phone:201-944-1260
Mailing Address - Fax:
Practice Address - Street 1:1625 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2748
Practice Address - Country:US
Practice Address - Phone:201-944-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty