Provider Demographics
NPI:1003108051
Name:ADVANCED DENTAL OF JERSEY CITY LLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL OF JERSEY CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:DEMETRIUS
Authorized Official - Last Name:TSAMBAZIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-586-4444
Mailing Address - Street 1:223 MALLORY AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1256
Mailing Address - Country:US
Mailing Address - Phone:201-232-3358
Mailing Address - Fax:
Practice Address - Street 1:223 MALLORY AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-1256
Practice Address - Country:US
Practice Address - Phone:201-232-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ182181223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty