Provider Demographics
NPI:1568686384
Name:ABA PEDIATRIC, LLC
Entity Type:Organization
Organization Name:ABA PEDIATRIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-386-0353
Mailing Address - Street 1:35 JOURNAL SQ
Mailing Address - Street 2:SUITE 601
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-4011
Mailing Address - Country:US
Mailing Address - Phone:201-386-0353
Mailing Address - Fax:201-386-0356
Practice Address - Street 1:35 JOURNAL SQ STE 601
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4011
Practice Address - Country:US
Practice Address - Phone:201-386-0353
Practice Address - Fax:201-386-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI019909001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7698704Medicaid