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General NPI Number Information
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NPI Number | 1558720698
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Entity Type | Organization
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Legal Business Name | GARDEN STATE SMILES OF NORTH BRUNSWICK
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Dates
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Enumeration Date | 02/17/2016
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Last Update Date | 02/17/2016
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Provider Practice Location Address
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Address Line | 1612 ROUTE 27
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City | NORTH BRUNSWICK
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State | NJ
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Zip | 08902-1451
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Country | US
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Telephone | 732-846-6767
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Fax |
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Provider Business Mailing Address
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Address Line | 1612 ROUTE 27
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City | NORTH BRUNSWICK
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State | NJ
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Zip | 08902-1451
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Country | US
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Telephone | 732-846-6767
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VLAD DETINICH
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Credential | DMD
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Telephone | 732-322-9297
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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 | DI021211
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License Number State | NJ
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