Provider Demographics
NPI:1710151089
Name:THE SMILE SPA OF NORTH JERSEY,LLC
Entity Type:Organization
Organization Name:THE SMILE SPA OF NORTH JERSEY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-445-2797
Mailing Address - Street 1:251 GODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1882
Mailing Address - Country:US
Mailing Address - Phone:201-445-2797
Mailing Address - Fax:201-445-8340
Practice Address - Street 1:251 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1882
Practice Address - Country:US
Practice Address - Phone:201-445-2797
Practice Address - Fax:201-445-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ141801223G0001X
NJ29205081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1301802Medicaid