Provider Demographics
NPI:1104930668
Name:COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY
Entity type:Organization
Organization Name:COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MANCINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-556-9600
Mailing Address - Street 1:3350 STATE ROUTE 138
Mailing Address - Street 2:STE 127
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9693
Mailing Address - Country:US
Mailing Address - Phone:732-556-9600
Mailing Address - Fax:732-556-9601
Practice Address - Street 1:3350 STATE ROUTE 138
Practice Address - Street 2:STE 127
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9693
Practice Address - Country:US
Practice Address - Phone:732-556-9600
Practice Address - Fax:732-556-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ11320OtherINS CO'S
NJ90730-00-4OtherNJ EMPLOYER ID