Provider Demographics
NPI:1942541677
Name:PEARLY WHITES PA
Entity Type:Organization
Organization Name:PEARLY WHITES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOLNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-464-6789
Mailing Address - Street 1:515 SPRINGFIELD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-1180
Mailing Address - Country:US
Mailing Address - Phone:908-464-6789
Mailing Address - Fax:
Practice Address - Street 1:501 SPRINGFIELD AVE FL 2
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-1180
Practice Address - Country:US
Practice Address - Phone:908-464-6789
Practice Address - Fax:908-464-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223E0200X, 1223G0001X, 1223P0300X, 1223S0112X
NJ22DI023493011223P0221X
NJ22DI023536011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty