Provider Demographics
NPI:1417492893
Name:ALL STAR FAMILY ORTHODONTICS
Entity Type:Organization
Organization Name:ALL STAR FAMILY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:VIVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-727-6666
Mailing Address - Street 1:3331 HIGHWAY 9 N
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2691
Mailing Address - Country:US
Mailing Address - Phone:732-727-6666
Mailing Address - Fax:
Practice Address - Street 1:3331 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2691
Practice Address - Country:US
Practice Address - Phone:732-727-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102246000261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental