Provider Demographics
NPI:1942797311
Name:HOLLYWOOD PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:HOLLYWOOD PEDIATRIC DENTISTRY
Other - Org Name:NUTLEY PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOLLYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-667-5507
Mailing Address - Street 1:500 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1720
Mailing Address - Country:US
Mailing Address - Phone:973-667-5507
Mailing Address - Fax:973-667-6150
Practice Address - Street 1:500 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1720
Practice Address - Country:US
Practice Address - Phone:973-667-5507
Practice Address - Fax:973-667-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025080001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty