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General NPI Number Information
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NPI Number | 1194861591
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Entity Type | Organization
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Legal Business Name | EAST BRUNSWICK PERIODONTICS AND DENTAL IMPLANTS
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | E 7 BRIER HILL CT
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-3336
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Country | US
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Telephone | 732-651-8470
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Fax | 732-651-8033
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Provider Business Mailing Address
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Address Line | E 7 BRIER HILL CT
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-3336
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Country | US
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Telephone | 732-651-8470
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Fax | 732-651-8033
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. NIMA MIR MADJLESSI
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Credential | DDS, MS, PA
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Telephone | 732-651-8470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 20508
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License Number State | NJ
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