Provider Demographics
NPI:1386883668
Name:STATE STREET SMILES PEDIATRIC DENTISTRY LLC.
Entity type:Organization
Organization Name:STATE STREET SMILES PEDIATRIC DENTISTRY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,FAAP
Authorized Official - Phone:201-487-7030
Mailing Address - Street 1:405 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-4421
Mailing Address - Country:US
Mailing Address - Phone:201-487-7030
Mailing Address - Fax:201-487-4418
Practice Address - Street 1:405 STATE ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4421
Practice Address - Country:US
Practice Address - Phone:201-487-7030
Practice Address - Fax:201-487-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD1213651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty