Provider Demographics
NPI:1073779047
Name:ST DENTAL
Entity Type:Organization
Organization Name:ST DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARYASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-479-3352
Mailing Address - Street 1:596 ANDERSON AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-1831
Mailing Address - Country:US
Mailing Address - Phone:973-479-3352
Mailing Address - Fax:
Practice Address - Street 1:596 ANDERSON AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1831
Practice Address - Country:US
Practice Address - Phone:973-479-3352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02030400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty