Eastern Dental of Elmwood Park, LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

EASTERN DENTAL OF ELMWOOD PARK, LLC

Practice address

100 Broadway
Elmwood Park, NJ 07407-3025

Phone

(732) 750-0707

NPI assigned

Jun 24, 2026

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Alex Petrik

Title

General Counsel

Phone

(248) 756-6738

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1782259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1782259200000",
    "number": "1013833284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "510 THORNALL ST STE 230",
            "city": "EDISON",
            "state": "NJ",
            "postal_code": "088372204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 BROADWAY",
            "city": "ELMWOOD PARK",
            "state": "NJ",
            "postal_code": "074073025",
            "telephone_number": "732-750-0707"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTERN DENTAL OF ELMWOOD PARK, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2026-06-24",
        "last_updated": "2026-06-24",
        "certification_date": "2026-06-24",
        "status": "A",
        "authorized_official_last_name": "PETRIK",
        "authorized_official_first_name": "ALEX",
        "authorized_official_title_or_position": "GENERAL COUNSEL",
        "authorized_official_telephone_number": "248-756-6738"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kelly Distefano, M.D.
• Thomas Dodd, L.C.A.D.C., C.S.W.
• Gregory I Dubover, D.D.S.
• Sheila Dunnells, PH.D., ADDICTIONS
• Taiel Durity-Choonoo
• David Eidman, D.D.S.
• Elevated Growth Behavioral Services LLC
• Elite Pediatrics LLC
• Elmwood Drugs Inc
• Elmwood Park Board of Education

• General Practice Dentistry in Elmwood Park, NJ
• Providers in Elmwood Park, NJ by specialty
• General Practice Dentistry in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.