Provider Demographics
NPI:1174540959
Name:MAXIM SULLA,DDS, PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:MAXIM SULLA,DDS, PROFESSIONAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-249-1010
Mailing Address - Street 1:1330 HOW LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1702
Mailing Address - Country:US
Mailing Address - Phone:732-249-1010
Mailing Address - Fax:732-220-0177
Practice Address - Street 1:1330 HOW LN
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1702
Practice Address - Country:US
Practice Address - Phone:732-249-1010
Practice Address - Fax:732-220-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 212051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty