Healthcare Provider Details

I. General information

NPI: 1912852682
Provider Name (Legal Business Name): STATE STREET-ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MAIN ST
HACKENSACK NJ
07601-5965
US

IV. Provider business mailing address

405 MAIN ST
HACKENSACK NJ
07601-5965
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-7030
  • Fax: 201-487-4418
Mailing address:
  • Phone: 201-487-7030
  • Fax: 201-487-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. EDWARD MICHAEL JACKSON
Title or Position: OWNER
Credential: DMD
Phone: 201-487-7030