Provider Demographics
NPI:1417291345
Name:UNION CITY SMILINE DENTAL, P.C.
Entity Type:Organization
Organization Name:UNION CITY SMILINE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:USHA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-372-5640
Mailing Address - Street 1:3906 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087
Mailing Address - Country:US
Mailing Address - Phone:201-330-7600
Mailing Address - Fax:201-330-0298
Practice Address - Street 1:3906 BERGENLINE AVE.
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087
Practice Address - Country:US
Practice Address - Phone:201-330-7600
Practice Address - Fax:201-330-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01912600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7421109Medicaid