Provider Demographics
NPI:1073066700
Name:GARDEN STATE SMILES OF BRICK
Entity Type:Organization
Organization Name:GARDEN STATE SMILES OF BRICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-477-5770
Mailing Address - Street 1:525 ROUTE 70
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-4022
Mailing Address - Country:US
Mailing Address - Phone:732-477-5770
Mailing Address - Fax:732-477-3433
Practice Address - Street 1:525 ROUTE 70 E
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723
Practice Address - Country:US
Practice Address - Phone:732-477-5770
Practice Address - Fax:732-477-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ94401223G0001X
NJ94341223G0001X
NJ212111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty