Healthcare Provider Details

I. General information

NPI: 1972737583
Provider Name (Legal Business Name): SMILE CENTRAL PASSAIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 MAIN AVE 3RD FLOOR
PASSAIC NJ
07055-4952
US

IV. Provider business mailing address

625 MAIN AVE 3RD FLOOR
PASSAIC NJ
07055-4952
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-1000
  • Fax: 973-574-1001
Mailing address:
  • Phone: 973-574-1000
  • Fax: 973-574-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02153300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02283000
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT GRUNSTEIN
Title or Position: OWNER
Credential: DMD
Phone: 201-658-8839