Provider Demographics
NPI:1699956490
Name:MERENE-BIANCO, JOHNIMEL LUSTERIO (DMD)
Entity type:Individual
Prefix:
First Name:JOHNIMEL
Middle Name:LUSTERIO
Last Name:MERENE-BIANCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NEWARK AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1326
Mailing Address - Country:US
Mailing Address - Phone:201-706-3412
Mailing Address - Fax:201-839-4557
Practice Address - Street 1:550 NEWARK AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1326
Practice Address - Country:US
Practice Address - Phone:201-706-3412
Practice Address - Fax:201-839-4557
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053320-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02898617Medicaid