Healthcare Provider Details

I. General information

NPI: 1205309143
Provider Name (Legal Business Name): SHINE PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3084 STATE ROUTE 27 STE 10
KENDALL PARK NJ
08824-1657
US

IV. Provider business mailing address

3084 STATE ROUTE 27 STE 10
KENDALL PARK NJ
08824-1657
US

V. Phone/Fax

Practice location:
  • Phone: 732-422-1100
  • Fax:
Mailing address:
  • Phone: 732-422-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SANJEEV SATWAH
Title or Position: OWNER
Credential:
Phone: 732-422-1100