Provider Demographics
NPI:1275798639
Name:AESTHETIC SMILES OF WAYNE PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:AESTHETIC SMILES OF WAYNE PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:973-696-2444
Mailing Address - Street 1:896 VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2971
Mailing Address - Country:US
Mailing Address - Phone:973-696-2444
Mailing Address - Fax:973-696-2888
Practice Address - Street 1:896 VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2971
Practice Address - Country:US
Practice Address - Phone:973-696-2444
Practice Address - Fax:973-696-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI021341001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty