Healthcare Provider Details

I. General information

NPI: 1710276365
Provider Name (Legal Business Name): ADVANCED ENDODONTICS ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PROSPECT AVE STE 7
HACKENSACK NJ
07601-1834
US

IV. Provider business mailing address

170 PROSPECT AVE STE 7
HACKENSACK NJ
07601-1834
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-8600
  • Fax: 201-343-8650
Mailing address:
  • Phone: 201-343-8600
  • Fax: 201-343-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22DI02237100
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0173151
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. MARYIA ROZENBLUM
Title or Position: OWNER
Credential: D.D.S
Phone: 201-343-8600