Provider Demographics
NPI:1043441876
Name:COMPREHENSIVE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:COMPREHENSIVE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YASMI
Authorized Official - Middle Name:O
Authorized Official - Last Name:CRYSTAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-356-1830
Mailing Address - Street 1:111 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1761
Mailing Address - Country:US
Mailing Address - Phone:732-356-1830
Mailing Address - Fax:
Practice Address - Street 1:111 E UNION AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1761
Practice Address - Country:US
Practice Address - Phone:732-356-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI159481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0188395Medicaid