Provider Demographics
NPI:1720258361
Name:DUONG, MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DUONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4405
Mailing Address - Country:US
Mailing Address - Phone:201-444-7447
Mailing Address - Fax:201-444-6833
Practice Address - Street 1:139 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4405
Practice Address - Country:US
Practice Address - Phone:201-444-7447
Practice Address - Fax:201-444-6833
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2016-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI224431223X0400X
NY0501421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0158267Medicaid