Provider Demographics
NPI:1669912952
Name:INNOVA DENTAL SOLUTIONS
Entity type:Organization
Organization Name:INNOVA DENTAL SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MADHAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNDURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-364-1700
Mailing Address - Street 1:155 S NEW PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-1734
Mailing Address - Country:US
Mailing Address - Phone:732-364-1700
Mailing Address - Fax:732-364-0870
Practice Address - Street 1:155 S NEW PROSPECT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-1734
Practice Address - Country:US
Practice Address - Phone:732-364-1700
Practice Address - Fax:732-364-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025677011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty