Provider Demographics
NPI:1710276365
Name:ADVANCED ENDODONTICS ALLIANCE
Entity Type:Organization
Organization Name:ADVANCED ENDODONTICS ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZENBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-343-8600
Mailing Address - Street 1:170 PROSPECT AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1834
Mailing Address - Country:US
Mailing Address - Phone:201-343-8600
Mailing Address - Fax:201-343-8650
Practice Address - Street 1:170 PROSPECT AVE STE 7
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1834
Practice Address - Country:US
Practice Address - Phone:201-343-8600
Practice Address - Fax:201-343-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022371001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0173151Medicaid