MEDICARE: GREEN BROOK FAMILY DENTALCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1223G0001X	NJ

General Provider Information

NPI Number	:	1386861227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN BROOK FAMILY DENTALCARE LLC

Provider Business Mailing Address
First Line	:	933 N WASHINGTON AVE
Second Line	:	STE. 1A
City	:	GREEN BROOK
State	:	NJ
Zip	:	08812-2614
Country	:	US
Telephone Number	:	732-968-8585
Fax Number	:	732-968-6569

Provider Business Practice Location Address
First Line	:	933 N WASHINGTON AVE
Second Line	:	STE. 1A
City	:	GREEN BROOK
State	:	NJ
Zip	:	08812-2614
Country	:	US
Telephone Number	:	732-968-8585
Fax Number	:	732-968-6569

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DENNIS PETRINI
Credential	:	D.M.D.
Telephone Number	:	732-968-8585

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/22/2020

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