Provider Demographics
NPI:1730685322
Name:DIMITREY, PAUL AMIL (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:AMIL
Last Name:DIMITREY
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 1:387 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3659
Mailing Address - Country:US
Mailing Address - Phone:201-463-5144
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI027567001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program