Provider Demographics
NPI:1285017624
Name:BRUNSWICK DENTAL GROUP
Entity type:Organization
Organization Name:BRUNSWICK DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-955-6907
Mailing Address - Street 1:415 STATE ROUTE 18
Mailing Address - Street 2:SUITE 13
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2305
Mailing Address - Country:US
Mailing Address - Phone:732-955-6907
Mailing Address - Fax:732-955-6837
Practice Address - Street 1:415 STATE ROUTE 18
Practice Address - Street 2:SUITE 13
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2305
Practice Address - Country:US
Practice Address - Phone:732-955-6907
Practice Address - Fax:732-955-6837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02412000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0235261Medicaid
NJ0233561Medicaid