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General NPI Number Information
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NPI Number | 1376053389
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Entity Type | Organization
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Legal Business Name | SMILIST DENTAL OF NEW JERSEY LLC
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Dates
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Enumeration Date | 10/04/2017
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Last Update Date | 10/04/2017
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Provider Practice Location Address
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Address Line | 305 SOUTH AVE
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City | GARWOOD
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State | NJ
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Zip | 07027-1343
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Country | US
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Telephone | 516-439-4756
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Fax |
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Provider Business Mailing Address
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Address Line | 40 CUTTERMILL RD STE 400
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City | GREAT NECK
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State | NY
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Zip | 11021-3213
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JAY KHORSANDI
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Credential | DDS
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Telephone | 516-439-4756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02564700
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02564700
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License Number State | NJ
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