1417502378 NPI number — PERIODONTAL CONSULTANTS, PA

Table of content: (NPI 1417502378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417502378 NPI number — PERIODONTAL CONSULTANTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIODONTAL CONSULTANTS, PA
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:
1417502378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 EAST MARLTON PIKE
Provider Second Line Business Mailing Address:
THE ATRIUM SUITE #2
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-428-4746
Provider Business Mailing Address Fax Number:
856-751-3975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 EAST MARLTON PIKE
Provider Second Line Business Practice Location Address:
THE ATRIUM SUITE #2
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-428-4746
Provider Business Practice Location Address Fax Number:
856-751-3975
Provider Enumeration Date:
08/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
AGOSTO
Authorized Official First Name:
RAFAELA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
267-334-0082

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0101051655 . This is a "BUSINESS IDENTIFICATION NUMBER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com