Provider Demographics
NPI:1497488985
Name:FRESH PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:FRESH PEDIATRIC DENTISTRY PC
Other - Org Name:SPARKLES DENTISTRY FOR CHILDREN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REESHA
Authorized Official - Middle Name:PATEL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-708-5108
Mailing Address - Street 1:214 50TH AVE
Mailing Address - Street 2:#507E
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5935
Mailing Address - Country:US
Mailing Address - Phone:617-708-5108
Mailing Address - Fax:
Practice Address - Street 1:39 SOUTH FULLERTON AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:347-979-2185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty