Provider Demographics
NPI:1194861591
Name:EAST BRUNSWICK PERIODONTICS AND DENTAL IMPLANTS
Entity Type:Organization
Organization Name:EAST BRUNSWICK PERIODONTICS AND DENTAL IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIR MADJLESSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, PA
Authorized Official - Phone:732-651-8470
Mailing Address - Street 1:E 7 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3336
Mailing Address - Country:US
Mailing Address - Phone:732-651-8470
Mailing Address - Fax:732-651-8033
Practice Address - Street 1:E 7 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3336
Practice Address - Country:US
Practice Address - Phone:732-651-8470
Practice Address - Fax:732-651-8033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ205081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1659303329OtherNATIONAL PROVIDER IDENTIF