Provider Demographics
NPI:1215103841
Name:SOUTH PATERSON DENTAL GROUP
Entity type:Organization
Organization Name:SOUTH PATERSON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-881-7800
Mailing Address - Street 1:32 HINE ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2955
Mailing Address - Country:US
Mailing Address - Phone:073-881-7800
Mailing Address - Fax:
Practice Address - Street 1:32 HINE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2955
Practice Address - Country:US
Practice Address - Phone:073-881-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO11259001223G0001X
NJ22DIO21978001223X0400X
NJ22DIO11009001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty