Provider Demographics
NPI:1023187697
Name:FAMILY & COSMETIC DENTISTRY OF N. BROAD, LLC
Entity type:Organization
Organization Name:FAMILY & COSMETIC DENTISTRY OF N. BROAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELVIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-352-7730
Mailing Address - Street 1:757 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2482
Mailing Address - Country:US
Mailing Address - Phone:908-352-7730
Mailing Address - Fax:908-353-8453
Practice Address - Street 1:757 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2482
Practice Address - Country:US
Practice Address - Phone:908-352-7730
Practice Address - Fax:908-353-8453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty