Provider Demographics
NPI:1427819895
Name:WYCKOFF DENTAL SPA LLC
Entity type:Organization
Organization Name:WYCKOFF DENTAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-801-9176
Mailing Address - Street 1:541 CEDAR HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2150
Mailing Address - Country:US
Mailing Address - Phone:201-444-2383
Mailing Address - Fax:
Practice Address - Street 1:541 CEDAR HILL AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2150
Practice Address - Country:US
Practice Address - Phone:201-444-2383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental