Provider Demographics
NPI:1386795409
Name:SUPREME DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:SUPREME DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:OSUALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-325-9800
Mailing Address - Street 1:331 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5302
Mailing Address - Country:US
Mailing Address - Phone:973-325-9800
Mailing Address - Fax:973-325-9877
Practice Address - Street 1:331 VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5302
Practice Address - Country:US
Practice Address - Phone:973-325-9800
Practice Address - Fax:973-325-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI021435001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty