1295582005 NPI number — LITTLE SMILES PEDIATRIC DENTISTRY OF SOUTH JERSEY

Table of content: (NPI 1295582005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295582005 NPI number — LITTLE SMILES PEDIATRIC DENTISTRY OF SOUTH JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE SMILES PEDIATRIC DENTISTRY OF SOUTH JERSEY
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:
6
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:
1295582005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1206 W SHERMAN AVE STE 4D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINELAND
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08360-6911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-368-2800
Provider Business Mailing Address Fax Number:
856-412-5100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1206 W SHERMAN AVE STE 4D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINELAND
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08360-6911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-368-2800
Provider Business Practice Location Address Fax Number:
856-412-5100
Provider Enumeration Date:
05/01/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MANDER
Authorized Official First Name:
DARLENE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING/AR
Authorized Official Telephone Number:
856-207-8406

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06371-03 . This is a "SPECIALTY PERMIT" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0490644 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22DI02457700 . This is a "DENTAL LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".