Provider Demographics
NPI:1730350984
Name:GITTLEMAN, MARILYN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:
Last Name:GITTLEMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 MADISON AVE
Mailing Address - Street 2:CENTER FOR HEALTH EDUCATON, MEDICINE AND DENTISTRY
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1251
Mailing Address - Country:US
Mailing Address - Phone:732-364-2144
Mailing Address - Fax:732-534-8064
Practice Address - Street 1:1771 MADISON AVE
Practice Address - Street 2:CENTER FOR HEALTH EDUCATON, MEDICINE AND DENTISTRY
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1251
Practice Address - Country:US
Practice Address - Phone:732-364-2144
Practice Address - Fax:732-534-8064
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01646600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0158411Medicaid