Provider Demographics
NPI:1598037996
Name:STRONG ROOTS DENTAL PC
Entity Type:Organization
Organization Name:STRONG ROOTS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAHAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-200-6002
Mailing Address - Street 1:273 NEWARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITH
Mailing Address - State:NJ
Mailing Address - Zip Code:07302
Mailing Address - Country:US
Mailing Address - Phone:551-200-6002
Mailing Address - Fax:201-984-0607
Practice Address - Street 1:273 NEWARK AVENUE
Practice Address - Street 2:
Practice Address - City:JERSEY CITH
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:551-200-6002
Practice Address - Fax:201-984-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024107011223G0001X
NJ22DIO24492001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0257761Medicaid