Healthcare Provider Details

I. General information

NPI: 1124585674
Provider Name (Legal Business Name): WILSON SMILES DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-51 WILSON AVE STE 2-D
NEWARK NJ
07105-3269
US

IV. Provider business mailing address

41-51 WILSON AVE STE 2-D
NEWARK NJ
07105-3269
US

V. Phone/Fax

Practice location:
  • Phone: 973-589-7337
  • Fax:
Mailing address:
  • Phone: 973-589-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. UMA KANIKICHARLA
Title or Position: CEO
Credential: MD
Phone: 732-857-7247