1861834749 NPI number — PREMIUM DENTAL SPECIALTIES, PC

Table of content: (NPI 1861834749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861834749 NPI number — PREMIUM DENTAL SPECIALTIES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIUM DENTAL SPECIALTIES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861834749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 N CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MOORESTOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08057-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-235-0020
Provider Business Mailing Address Fax Number:
856-235-0017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT HOLLY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08060-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-235-4696
Provider Business Practice Location Address Fax Number:
856-235-0017
Provider Enumeration Date:
07/22/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
APPELSTEIN
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER/ ENDODONTIST
Authorized Official Telephone Number:
856-235-4696

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  22DI02143800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X , with the licence number: 22DI02035800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)