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General NPI Number Information
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NPI Number | 1841319209
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Entity Type | Organization
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Legal Business Name | EAST BRUNSWICK DENTAL STUDIO, LLC
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 11/03/2009
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Provider Practice Location Address
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Address Line | 573 CRANBURY RD SUITE A-1
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-4026
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Country | US
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Telephone | 732-613-1931
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Fax |
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Provider Business Mailing Address
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Address Line | 573 CRANBURY RD SUITE A-1
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-4026
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Country | US
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Telephone | 732-613-1931
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | GENEVIEVE M FERNANDES
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Credential | B.D.S., D.D.S.
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Telephone | 732-613-1931
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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 | DI19669
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License Number State | NJ
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