Healthcare Provider Details

I. General information

NPI: 1720007776
Provider Name (Legal Business Name): MAXIM SULLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 HOW LN
NORTH BRUNSWICK NJ
08902-1702
US

IV. Provider business mailing address

1330 HOW LN
NORTH BRUNSWICK NJ
08902-1702
US

V. Phone/Fax

Practice location:
  • Phone: 732-249-1010
  • Fax: 732-220-0177
Mailing address:
  • Phone: 732-249-1010
  • Fax: 732-220-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDI21205
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: