Provider Demographics
NPI:1790868701
Name:OM DENTAL CARE PC
Entity Type:Organization
Organization Name:OM DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HITESH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-222-0002
Mailing Address - Street 1:480 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307
Mailing Address - Country:US
Mailing Address - Phone:201-222-0002
Mailing Address - Fax:201-222-8211
Practice Address - Street 1:480 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-222-0002
Practice Address - Fax:201-222-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI188621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG150101Medicaid