Provider Demographics
NPI:1992866537
Name:EASTERN ORTHODONTIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:EASTERN ORTHODONTIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ORTHODONTICS
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-750-2730
Mailing Address - Street 1:1030 SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1390
Practice Address - Country:US
Practice Address - Phone:732-750-2730
Practice Address - Fax:732-636-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ097441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty