Provider Demographics
NPI:1649773524
Name:NEW LEAF PEDIATRIC DENTAL LLC
Entity Type:Organization
Organization Name:NEW LEAF PEDIATRIC DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERISH
Authorized Official - Middle Name:
Authorized Official - Last Name:IM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-592-0758
Mailing Address - Street 1:513 ROFF AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2029 LEMOINE AVE STE 203
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5731
Practice Address - Country:US
Practice Address - Phone:201-592-0758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty