Provider Demographics
NPI:1164781746
Name:ADVANCED ORAL REHABILITAION
Entity Type:Organization
Organization Name:ADVANCED ORAL REHABILITAION
Other - Org Name:BRANFORD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WOO IL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-424-0040
Mailing Address - Street 1:23 BRANFORD PLACE
Mailing Address - Street 2:
Mailing Address - City:NEWARK NJ
Mailing Address - State:NJ
Mailing Address - Zip Code:07105
Mailing Address - Country:US
Mailing Address - Phone:973-424-0040
Mailing Address - Fax:973-424-0089
Practice Address - Street 1:23 BRANFORD PLACE
Practice Address - Street 2:
Practice Address - City:NEWARK NJ
Practice Address - State:NJ
Practice Address - Zip Code:07105
Practice Address - Country:US
Practice Address - Phone:973-424-0040
Practice Address - Fax:973-424-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023247001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0252727Medicaid