Healthcare Provider Details

I. General information

NPI: 1326413402
Provider Name (Legal Business Name): PEARLY WHITES SPEC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SPRINGFIELD AVE
BERKELEY HEIGHTS NJ
07922
US

IV. Provider business mailing address

501B SPRINGFIELD AVE
BERKELEY HEIGHTS NJ
07922-1180
US

V. Phone/Fax

Practice location:
  • Phone: 973-578-8788
  • Fax:
Mailing address:
  • Phone: 973-578-8788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KATE RODRIGUES
Title or Position: BILLING COORDINATOR
Credential:
Phone: 973-578-8788