Healthcare Provider Details

I. General information

NPI: 1497488985
Provider Name (Legal Business Name): FRESH PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SOUTH FULLERTON AVE SUITE 10
MONTCLAIR NJ
07042
US

IV. Provider business mailing address

214 50TH AVE #507E
LONG ISLAND CITY NY
11101-5935
US

V. Phone/Fax

Practice location:
  • Phone: 347-979-2185
  • Fax:
Mailing address:
  • Phone: 617-708-5108
  • 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. REESHA PATEL SHAH
Title or Position: OWNER
Credential: DMD
Phone: 617-708-5108