Provider Demographics
NPI:1790100360
Name:HEALTHY SMILES OF GLOUCESTER CITY
Entity Type:Organization
Organization Name:HEALTHY SMILES OF GLOUCESTER CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOONI
Authorized Official - Middle Name:DILIP
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-456-2682
Mailing Address - Street 1:535 MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1502
Mailing Address - Country:US
Mailing Address - Phone:856-456-2682
Mailing Address - Fax:
Practice Address - Street 1:535 MONMOUTH ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1502
Practice Address - Country:US
Practice Address - Phone:856-456-2682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty