Provider Demographics
NPI:1104009943
Name:PEDIATRIC DENTISTRY OF SOUTH JERSEY, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF SOUTH JERSEY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-205-0099
Mailing Address - Street 1:3071 E CHESTNUT AVE
Mailing Address - Street 2:SUITE D-10
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7847
Mailing Address - Country:US
Mailing Address - Phone:856-205-0099
Mailing Address - Fax:856-205-1633
Practice Address - Street 1:3071 E CHESTNUT AVE
Practice Address - Street 2:SUITE D-10
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-7847
Practice Address - Country:US
Practice Address - Phone:856-205-0099
Practice Address - Fax:856-205-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-16
Last Update Date:2007-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI166461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty