Provider Demographics
NPI:1114216496
Name:LAWRENCEVILLE DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:LAWRENCEVILLE DENTAL ASSOCIATES, LLC
Other - Org Name:SIMPLY BEAUTIFUL SMILES OF LAWRENCEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-883-1770
Mailing Address - Street 1:1200 LAWRENCEVILLE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-3551
Mailing Address - Country:US
Mailing Address - Phone:609-883-1770
Mailing Address - Fax:609-883-1777
Practice Address - Street 1:1200 LAWRENCEVILLE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-3551
Practice Address - Country:US
Practice Address - Phone:609-883-1770
Practice Address - Fax:609-883-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01462203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty