Provider Demographics
NPI:1174930200
Name:MAGOULAS, PETER J (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MAGOULAS
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:PO BOX 7987
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-7987
Mailing Address - Country:US
Mailing Address - Phone:732-544-9002
Mailing Address - Fax:732-544-9022
Practice Address - Street 1:167 AVENUE AT THE CMN
Practice Address - Street 2:SUITE 16
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4805
Practice Address - Country:US
Practice Address - Phone:732-544-9002
Practice Address - Fax:732-544-9022
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ85901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics