Provider Demographics
NPI:1447661491
Name:DIAMOND BRACES EDISON
Entity type:Organization
Organization Name:DIAMOND BRACES EDISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-420-7116
Mailing Address - Street 1:15 ENGLE ST
Mailing Address - Street 2:SUITE #303
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2936
Mailing Address - Country:US
Mailing Address - Phone:201-308-8181
Mailing Address - Fax:718-373-6799
Practice Address - Street 1:34-36 PROGRESS ST
Practice Address - Street 2:SUITE A4
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1197
Practice Address - Country:US
Practice Address - Phone:908-222-8228
Practice Address - Fax:718-373-6799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI20707001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8072701Medicaid