Provider Demographics
NPI:1104920602
Name:GLADSTONE, JAY ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ROBERT
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:ROBERT
Other - Last Name:GLADSTONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:626 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-9301
Mailing Address - Country:US
Mailing Address - Phone:908-688-1039
Mailing Address - Fax:908-688-1041
Practice Address - Street 1:626 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9301
Practice Address - Country:US
Practice Address - Phone:908-688-1039
Practice Address - Fax:908-688-1041
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice