Provider Demographics
NPI:1629089909
Name:SMILE CENTRAL DENTAL PC
Entity Type:Organization
Organization Name:SMILE CENTRAL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-742-4200
Mailing Address - Street 1:140 MARKET STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505
Mailing Address - Country:US
Mailing Address - Phone:973-742-4200
Mailing Address - Fax:973-742-4997
Practice Address - Street 1:140 MARKET STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505
Practice Address - Country:US
Practice Address - Phone:973-742-4200
Practice Address - Fax:973-742-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI21533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0083518Medicaid