Provider Demographics
NPI:1285204347
Name:SOUTH AVENUE DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTH AVENUE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAJJA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-889-5379
Mailing Address - Street 1:1106 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1661
Mailing Address - Country:US
Mailing Address - Phone:646-483-8824
Mailing Address - Fax:
Practice Address - Street 1:104 SOUTH AVE E
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2944
Practice Address - Country:US
Practice Address - Phone:203-889-5379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental