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General NPI Number Information
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NPI Number | 1710606488
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Entity Type | Organization
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Legal Business Name | AESTHESTIC & IMPLANT DENTAL ASSOCIATES PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/25/2022
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Last Update Date | 08/25/2022
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Provider Practice Location Address
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Address Line | 155 N DEAN ST STE B
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-2532
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Country | US
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Telephone | 201-568-6465
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Fax |
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Provider Business Mailing Address
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Address Line | 155 N DEAN ST
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-2532
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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 | CREDENTIALING SPECIALIST
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Name | JESSICA DESKINS
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Credential |
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Telephone | 724-466-2644
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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 |
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License Number State |
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