Healthcare Provider Details

I. General information

NPI: 1982014114
Provider Name (Legal Business Name): JERSEY SMILE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MAIN ST
SPOTSWOOD NJ
08884-1739
US

IV. Provider business mailing address

407 MAIN ST
SPOTSWOOD NJ
08884-1739
US

V. Phone/Fax

Practice location:
  • Phone: 732-387-2360
  • Fax: 732-387-2561
Mailing address:
  • Phone: 732-387-2360
  • Fax: 732-387-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number22DI02322000
License Number StateNJ

VIII. Authorized Official

Name: DR. SVETLANA KONSTANTINOVA
Title or Position: CO-OWNER/DENTIST
Credential: D.D.S.
Phone: 732-387-2360