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General NPI Number Information
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NPI Number | 1275798639
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Entity Type | Organization
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Legal Business Name | AESTHETIC SMILES OF WAYNE PROFESSIONAL ASSOCIATION
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Dates
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Enumeration Date | 07/25/2008
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Last Update Date | 07/25/2008
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Provider Practice Location Address
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Address Line | 896 VALLEY ROAD
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City | WAYNE
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State | NJ
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Zip | 07470-2971
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Country | US
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Telephone | 973-696-2444
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Fax | 973-696-2888
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Provider Business Mailing Address
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Address Line | 896 VALLEY ROAD
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City | WAYNE
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State | NJ
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Zip | 07470-2971
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Country | US
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Telephone | 973-696-2444
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Fax | 973-696-2888
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Authorized Official
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Title or Position | OWNER OFFICE MANAGER
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Name | HENRY ELLIS III
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Credential |
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Telephone | 973-696-2444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02134100
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License Number State | NJ
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