Provider Demographics
NPI:1962583385
Name:IANZANO, JOHN (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:IANZANO
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-2646
Mailing Address - Country:US
Mailing Address - Phone:201-447-9700
Mailing Address - Fax:646-536-3187
Practice Address - Street 1:545 ROUTE 17 SOUTH
Practice Address - Street 2:SUITE 2007
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-447-9700
Practice Address - Fax:201-447-4099
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ12955122300000X
NY040118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist