Provider Demographics
NPI:1558720698
Name:GARDEN STATE SMILES OF NORTH BRUNSWICK
Entity Type:Organization
Organization Name:GARDEN STATE SMILES OF NORTH BRUNSWICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VLAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DETINICH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-322-9297
Mailing Address - Street 1:1612 ROUTE 27
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1451
Mailing Address - Country:US
Mailing Address - Phone:732-846-6767
Mailing Address - Fax:
Practice Address - Street 1:1612 ROUTE 27
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1451
Practice Address - Country:US
Practice Address - Phone:732-846-6767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0212111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty