1497101430 NPI number — SOUTH JERSEY DENTAL SLEEP CENTER LLC

Table of content: PAIGE JA NE LOCKHART MA, BCBA (NPI 1609659648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497101430 NPI number — SOUTH JERSEY DENTAL SLEEP CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH JERSEY DENTAL SLEEP CENTER LLC
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:
1497101430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08055-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-953-7199
Provider Business Mailing Address Fax Number:
609-953-0314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08055-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-953-7199
Provider Business Practice Location Address Fax Number:
609-953-0314
Provider Enumeration Date:
05/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HOOVER
Authorized Official First Name:
KEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
609-953-7199

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  DI01615200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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