Provider Demographics
NPI:1073767281
Name:CENTRAL JERSEY PEDIATRIC DENTISTRY & ORTHODONTICS LLC
Entity Type:Organization
Organization Name:CENTRAL JERSEY PEDIATRIC DENTISTRY & ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:BACKHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-257-5588
Mailing Address - Street 1:176 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4908
Mailing Address - Country:US
Mailing Address - Phone:732-257-5588
Mailing Address - Fax:732-257-9189
Practice Address - Street 1:176 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4908
Practice Address - Country:US
Practice Address - Phone:732-257-5588
Practice Address - Fax:732-257-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022920001223P0221X
NJ22DI022951001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty