Provider Demographics
NPI:1386861227
Name:GREEN BROOK FAMILY DENTALCARE LLC
Entity Type:Organization
Organization Name:GREEN BROOK FAMILY DENTALCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRINI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-968-8585
Mailing Address - Street 1:933 N WASHINGTON AVE
Mailing Address - Street 2:STE. 1A
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-2614
Mailing Address - Country:US
Mailing Address - Phone:732-968-8585
Mailing Address - Fax:732-968-6569
Practice Address - Street 1:933 N WASHINGTON AVE
Practice Address - Street 2:STE. 1A
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-2614
Practice Address - Country:US
Practice Address - Phone:732-968-8585
Practice Address - Fax:732-968-6569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223G0001X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherDENTAL GROUP PRACTICE