Healthcare Provider Details

I. General information

NPI: 1790219772
Provider Name (Legal Business Name): EASTERN DENTAL OF HACKENSACK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 HACKENSACK AVENUE, SUITE 4
HACKENSACK NJ
07601
US

IV. Provider business mailing address

1030 ST. GEORGES AVENUE
AVENEL NJ
07001
US

V. Phone/Fax

Practice location:
  • Phone: 201-347-5033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01080400
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MICHAEL SLOMOVITZ
Title or Position: OWNER
Credential: DDS
Phone: 732-750-0707