Basic Information
| Provider Information | |||||||||
| NPI: | 1114065406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMANGULI | ||||||||
| FirstName: | MATIN | ||||||||
| MiddleName: | MIKAYIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 PATERSON ST STE 4100 | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357757 | ||||||||
| FaxNumber: | 7322357095 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 PATERSON ST STE 4100 | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357757 | ||||||||
| FaxNumber: | 7322357095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401411071 | VA | N | Dental Providers | Dentist | 207Y00000X | Q0461 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 36041 | AL | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 25MA10294300 | NJ | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0007X | 25MA10294300 | NJ | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 841629676 | 01 | VA | TAX IDENTIFICATION | OTHER | 113660124 | 01 | VA | TAX IDENTIFICATION | OTHER | 542034392 | 01 | VA | TAX IDENTIFICATION | OTHER |