# SURGERY CENTER OF PENTHOUSE IV

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1710060496
- **Authorized official:** DR. THEODORE A NIEBLOOM DMD (DOCTOR ADMINISTRATIVE DIRECTOR)
- **Authorized official phone:** (973) 736-7616

## Contact information

- **Practice address:** 101 OLD SHORT HILLS ROAD, WEST ORANGE, NJ 07052
- **Practice address phone:** (973) 736-1345
- **Practice address fax:** (973) 325-3487
- **Mailing address:** 101 OLD SHORT HILLS ROAD, WEST ORANGE, NJ 07052
- **Mailing address phone:** (973) 736-1345
- **Mailing address fax:** (973) 325-3487

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 10/24/2006
- **Last updated:** 08/22/2020