Healthcare Provider Details

I. General information

NPI: 1780990622
Provider Name (Legal Business Name): GROVE STREET DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 06/21/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 NEWARK AVE SUITE 2B
JERSEY CITY NJ
07302-2859
US

IV. Provider business mailing address

175 NEWARK AVE SUITE 2B
JERSEY CITY NJ
07302-2859
US

V. Phone/Fax

Practice location:
  • Phone: 201-200-0222
  • Fax:
Mailing address:
  • Phone: 201-200-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02366200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSHMA HALTHORE
Title or Position: PRESIDENT
Credential: DMD
Phone: 201-200-0222