Provider Demographics
NPI:1952430332
Name:ISLAM, TAJUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAJUL
Middle Name:
Last Name:ISLAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COMMUNITY DRIVE
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-8992
Mailing Address - Country:US
Mailing Address - Phone:570-243-8777
Mailing Address - Fax:570-243-8778
Practice Address - Street 1:300 COMMUNITY DRIVE
Practice Address - Street 2:SUITE C-2
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-8992
Practice Address - Country:US
Practice Address - Phone:570-243-8777
Practice Address - Fax:570-243-8778
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0505811223G0001X
PADS0385351223G0001X
NY0805811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102593018Medicaid
NY9179252OtherDORAL DENTAL IPA OF NY
NY02392501Medicaid