Provider Demographics
NPI:1104847805
Name:SOMERDALE FAMILY DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:SOMERDALE FAMILY DENTAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REBHUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-783-3499
Mailing Address - Street 1:205 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-1646
Mailing Address - Country:US
Mailing Address - Phone:856-783-3499
Mailing Address - Fax:856-783-9582
Practice Address - Street 1:205 N WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1646
Practice Address - Country:US
Practice Address - Phone:856-783-3499
Practice Address - Fax:856-783-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ13496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2655705Medicaid