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General NPI Number Information
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NPI Number | 1871919779
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Entity Type | Organization
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Legal Business Name | MOUNTAIN LAKES PREMIER DENTAL , LLC
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Dates
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Enumeration Date | 03/15/2014
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Last Update Date | 06/04/2015
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Provider Practice Location Address
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Address Line | 420 BOULEVARD SUITE#102
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City | MOUNTAIN LAKES
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State | NJ
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Zip | 07046-1742
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Country | US
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Telephone | 973-263-2770
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Fax | 973-263-1291
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Provider Business Mailing Address
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Address Line | 420 BOULEVARD SUITE#102
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City | MOUNTAIN LAKES
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State | NJ
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Zip | 07046-1742
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Country | US
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Telephone | 973-263-2770
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Fax | 973-263-1291
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. NESRINE BESTANDJI
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Credential | D.M.D.
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Telephone | 973-263-2770
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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 | 22DI02456600
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02466900
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License Number State | NJ
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