Provider Demographics
NPI:1750809232
Name:GREAT SMILES ORTHODONTICS
Entity type:Organization
Organization Name:GREAT SMILES ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PANKAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PURI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-347-5724
Mailing Address - Street 1:8 DEBRA CT
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-2827
Mailing Address - Country:US
Mailing Address - Phone:908-347-5724
Mailing Address - Fax:
Practice Address - Street 1:559 SPEEDWELL AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-2122
Practice Address - Country:US
Practice Address - Phone:908-347-5724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI207331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty