Healthcare Provider Details

I. General information

NPI: 1770192239
Provider Name (Legal Business Name): EASTERN DENTAL HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 ST. GEORGES AVENUE SUITE 304
AVENEL NJ
07001-1327
US

IV. Provider business mailing address

1030 ST. GEORGES AVENUE SUITE 304
AVENEL NJ
07001-1327
US

V. Phone/Fax

Practice location:
  • Phone: 732-750-0707
  • Fax: 732-750-5781
Mailing address:
  • Phone: 732-750-0707
  • Fax: 732-750-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELAN SCHWARZ
Title or Position: OWNER
Credential: DMD
Phone: 816-953-5400