1730587783 NPI number — BRIGHT SMILE A VISITING DENTAL SERVICE OF NJ LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730587783 NPI number — BRIGHT SMILE A VISITING DENTAL SERVICE OF NJ LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIGHT SMILE A VISITING DENTAL SERVICE OF NJ LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730587783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1999 CEDAR BRIDGE AVE
Provider Second Line Business Mailing Address:
STE 3D
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-670-0097
Provider Business Mailing Address Fax Number:
201-445-0225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1999 CEDAR BRIDGE AVE
Provider Second Line Business Practice Location Address:
STE 3D
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-670-0097
Provider Business Practice Location Address Fax Number:
201-445-0225
Provider Enumeration Date:
12/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STATFELD
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
201-670-0097

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0448354 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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