Provider Demographics
NPI:1548500283
Name:GANGOLI, NITISH
Entity type:Individual
Prefix:
First Name:NITISH
Middle Name:
Last Name:GANGOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07933-2014
Mailing Address - Country:US
Mailing Address - Phone:201-317-9678
Mailing Address - Fax:
Practice Address - Street 1:901 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5105
Practice Address - Country:US
Practice Address - Phone:201-659-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-17
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025398001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery