Provider Demographics
NPI:1427115229
Name:MONTVILLE DERMATOLOGY AND LASER CENTER
Entity type:Organization
Organization Name:MONTVILLE DERMATOLOGY AND LASER CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:BILKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-402-1563
Mailing Address - Street 1:350 MAIN RD
Mailing Address - Street 2:SUITE - 103
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9222
Mailing Address - Country:US
Mailing Address - Phone:973-402-1563
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN RD
Practice Address - Street 2:SUITE - 103
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9222
Practice Address - Country:US
Practice Address - Phone:973-402-1563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ653958Medicare ID - Type UnspecifiedPROVIDER ID NUMBER
NJE57391Medicare UPIN