Provider Demographics
NPI:1083936611
Name:LTC MOBILE DENTAL SERVICES, P.A.
Entity Type:Organization
Organization Name:LTC MOBILE DENTAL SERVICES, P.A.
Other - Org Name:LTC MOBILE DENTAL SERVICES, P.A.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GVILDYS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:551-404-5769
Mailing Address - Street 1:1961 MORRIS AVE
Mailing Address - Street 2:SUITE A-7
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3531
Mailing Address - Country:US
Mailing Address - Phone:551-404-5769
Mailing Address - Fax:866-810-8101
Practice Address - Street 1:1961 MORRIS AVE
Practice Address - Street 2:SUITE A-7
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3531
Practice Address - Country:US
Practice Address - Phone:551-404-5769
Practice Address - Fax:866-810-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01820201122300000X
NJ22DI02289100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1427108307Medicaid
NJ1700917127Medicaid
NJ1285785006Medicaid