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General NPI Number Information
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NPI Number | 1568686384
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Entity Type | Organization
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Legal Business Name | ABA PEDIATRIC, LLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 35 JOURNAL SQ STE 601
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City | JERSEY CITY
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State | NJ
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Zip | 07306-4011
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Country | US
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Telephone | 201-386-0353
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Fax | 201-386-0356
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Provider Business Mailing Address
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Address Line | 35 JOURNAL SQ SUITE 601
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City | JERSEY CITY
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State | NJ
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Zip | 07306-4011
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Country | US
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Telephone | 201-386-0353
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Fax | 201-386-0356
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Authorized Official
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Title or Position | DENTIST
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Name | DMITRY SHTILMAN
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Credential | DDS
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Telephone | 201-386-0353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 22DI01990900
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License Number State | NJ
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