Healthcare Provider Details

I. General information

NPI: 1730731647
Provider Name (Legal Business Name): GARDEN STATE DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 304
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

385 PROSPECT AVE STE 304
HACKENSACK NJ
07601-2570
US

V. Phone/Fax

Practice location:
  • Phone: 201-298-8000
  • Fax: 719-823-6996
Mailing address:
  • Phone: 201-298-8000
  • Fax: 719-823-6996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: VICTORIA KUSHENSKY
Title or Position: OWNER / AO
Credential: DDS
Phone: 201-298-8000