Provider Demographics
NPI:1205833498
Name:SUMMIT DENTIST
Entity Type:Organization
Organization Name:SUMMIT DENTIST
Other - Org Name:AESTHETIC DENTISTRY OF SUMMIT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:OK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-273-3873
Mailing Address - Street 1:52 DEFOREST AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:908-273-3873
Mailing Address - Fax:908-273-0905
Practice Address - Street 1:52 DEFOREST AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-1930
Practice Address - Country:US
Practice Address - Phone:908-273-3873
Practice Address - Fax:908-273-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22-DI02025200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty