Provider Demographics
NPI:1821159302
Name:GRAND DENTAL, PC
Entity Type:Organization
Organization Name:GRAND DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARCES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-816-8696
Mailing Address - Street 1:106 GRAND AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3574
Mailing Address - Country:US
Mailing Address - Phone:201-816-8696
Mailing Address - Fax:201-816-9552
Practice Address - Street 1:106 GRAND AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3574
Practice Address - Country:US
Practice Address - Phone:201-816-8696
Practice Address - Fax:201-816-9552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0214951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty