Healthcare Provider Details

I. General information

NPI: 1720405764
Provider Name (Legal Business Name): ADVANCED DENTAL SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SYLVAN AVENUE
ENGLEWOOD CLIFFS NJ
07632
US

IV. Provider business mailing address

7 SYLVAN AVENUE
ENGLEWOOD CLIFFS NJ
07632
US

V. Phone/Fax

Practice location:
  • Phone: 201-302-0700
  • Fax: 201-302-9857
Mailing address:
  • Phone: 201-302-0700
  • Fax: 201-302-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number18599
License Number StateNJ

VIII. Authorized Official

Name: DR. ALEXANDER E. LEE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 201-302-0700