Provider Demographics
NPI:1851738736
Name:REJUVENATE DENTAL SLEEP MEDICINE
Entity Type:Organization
Organization Name:REJUVENATE DENTAL SLEEP MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODESTO-GARRIDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-652-0400
Mailing Address - Street 1:266 HARRISTOWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3302
Mailing Address - Country:US
Mailing Address - Phone:201-652-0400
Mailing Address - Fax:201-447-5762
Practice Address - Street 1:266 HARRISTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3302
Practice Address - Country:US
Practice Address - Phone:201-652-0400
Practice Address - Fax:201-447-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI018255001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7340250001Medicare NSC