Provider Demographics
NPI:1154574465
Name:CENTER FOR FAMILY DENTISTRY
Entity type:Organization
Organization Name:CENTER FOR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:FARIBA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARIFAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-375-0400
Mailing Address - Street 1:1187 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1187 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111
Practice Address - Country:US
Practice Address - Phone:973-375-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0202951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60025186OtherHORIZON NJ HEALTH
NJ0110221-01Medicaid
NJ000000299601OtherAMERICHOICE
NJ011070OtherDORAL DENTAL