Healthcare Provider Details

I. General information

NPI: 1740720614
Provider Name (Legal Business Name): HUDSON RIVER BRACES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 ABBOTT BLVD SUITE 301
FORT LEE NJ
07024-4151
US

IV. Provider business mailing address

810 ABBOTT BLVD SUITE 301
FORT LEE NJ
07024-4151
US

V. Phone/Fax

Practice location:
  • Phone: 201-224-3600
  • Fax:
Mailing address:
  • Phone: 201-224-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02575602
License Number StateNJ

VIII. Authorized Official

Name: DR. CASSANDRA GANDIA
Title or Position: ORTHODONTIST
Credential: D.D.S.
Phone: 201-774-3344