Healthcare Provider Details

I. General information

NPI: 1710151089
Provider Name (Legal Business Name): THE SMILE SPA OF NORTH JERSEY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 GODWIN AVE
MIDLAND PARK NJ
07432-1882
US

IV. Provider business mailing address

251 GODWIN AVE
MIDLAND PARK NJ
07432-1882
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-2797
  • Fax: 201-445-8340
Mailing address:
  • Phone: 201-445-2797
  • Fax: 201-445-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14180
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2920508
License Number StateNJ

VIII. Authorized Official

Name: DR. DEBRA ROSENBLATT
Title or Position: PROPRIETER
Credential: DDS
Phone: 201-445-2797