Provider Demographics
NPI:1548544471
Name:SPARKLE KIDS DENTISTRY PC
Entity type:Organization
Organization Name:SPARKLE KIDS DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PREETI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-475-1600
Mailing Address - Street 1:15-01 BROADWAY STE 18
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY STE 18
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6018
Practice Address - Country:US
Practice Address - Phone:201-475-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02285400122300000X, 1223S0112X
NJ22DI022904001223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty