Healthcare Provider Details

I. General information

NPI: 1194861591
Provider Name (Legal Business Name): EAST BRUNSWICK PERIODONTICS AND DENTAL IMPLANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

E 7 BRIER HILL CT
EAST BRUNSWICK NJ
08816-3336
US

IV. Provider business mailing address

E 7 BRIER HILL CT
EAST BRUNSWICK NJ
08816-3336
US

V. Phone/Fax

Practice location:
  • Phone: 732-651-8470
  • Fax: 732-651-8033
Mailing address:
  • Phone: 732-651-8470
  • Fax: 732-651-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20508
License Number StateNJ

VIII. Authorized Official

Name: DR. NIMA MIR MADJLESSI
Title or Position: DOCTOR
Credential: DDS, MS, PA
Phone: 732-651-8470