1710552278 NPI number — CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710552278 NPI number — CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S DENTAL SURGERY CENTER OF JACKSON 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:
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:
1710552278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 WILLOWBROOK LN STE 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST CHESTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19382-5594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-575-2321
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 S COOKS BRIDGE RD STE 2-3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08527-2462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-928-1099
Provider Business Practice Location Address Fax Number:
732-833-1690
Provider Enumeration Date:
05/26/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LE
Authorized Official First Name:
VAN PHI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING CONTRACTS MANAGER
Authorized Official Telephone Number:
267-575-2321

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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