Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DI 20875 | NJ |
NPI | 1003028200 |
---|---|
Provider Name | Dr. Justin Jay Fried |
First Address | Maplewood, NJ 07040-2640 |
Second Address | Maplewood, NJ 07040-2640 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 08/07/2007 |