Provider Demographics
NPI:1033587381
Name:GLOW DENTAL SPA P.C.
Entity Type:Organization
Organization Name:GLOW DENTAL SPA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEHSHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AHKAMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-942-6550
Mailing Address - Street 1:506 HAMBURG TPKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2068
Mailing Address - Country:US
Mailing Address - Phone:973-942-6550
Mailing Address - Fax:973-942-6553
Practice Address - Street 1:506 HAMBURG TPKE
Practice Address - Street 2:SUITE 101
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2068
Practice Address - Country:US
Practice Address - Phone:973-942-6550
Practice Address - Fax:973-942-6553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI020826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ24362NJMedicaid