Provider Demographics
NPI:1174223572
Name:MONTCLAIR ORTHODONTICS, LLC
Entity type:Organization
Organization Name:MONTCLAIR ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RUBINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-744-1912
Mailing Address - Street 1:218 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1915
Mailing Address - Country:US
Mailing Address - Phone:973-744-1912
Mailing Address - Fax:973-744-5955
Practice Address - Street 1:218 LORRAINE AVE
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1915
Practice Address - Country:US
Practice Address - Phone:973-744-1912
Practice Address - Fax:973-744-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396930855OtherNPPES
NJ22DI02349400OtherNJ STATE BOARD OF DENTISTRY
1134251606OtherNPPES
NJ22DI01426800OtherNJ STATE BOARD OF DENTISTRY