Provider Demographics
NPI:1083806582
Name:LAKEWOOD FAMILY AND COSMETIC DENTAL CARE, PC
Entity Type:Organization
Organization Name:LAKEWOOD FAMILY AND COSMETIC DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:TABAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-364-5505
Mailing Address - Street 1:500 RIVER AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4738
Mailing Address - Country:US
Mailing Address - Phone:732-364-5505
Mailing Address - Fax:732-364-5595
Practice Address - Street 1:500 RIVER AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4738
Practice Address - Country:US
Practice Address - Phone:732-364-5505
Practice Address - Fax:732-364-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02295200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty