Provider Demographics
NPI:1417335985
Name:PEARL SMILE DENTAL PC
Entity Type:Organization
Organization Name:PEARL SMILE DENTAL PC
Other - Org Name:WEST NEW YORK DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RASHID
Authorized Official - Middle Name:I
Authorized Official - Last Name:KHALID
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-866-3000
Mailing Address - Street 1:4900 BERGENLINE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-1611
Mailing Address - Country:US
Mailing Address - Phone:201-866-3000
Mailing Address - Fax:201-866-3001
Practice Address - Street 1:4900 BERGENLINE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-1611
Practice Address - Country:US
Practice Address - Phone:201-866-3000
Practice Address - Fax:201-866-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025086001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0310867Medicaid