Provider Demographics
NPI:1114200912
Name:MEDFORD CHILDREN'S DENTAL CENTER, PC
Entity Type:Organization
Organization Name:MEDFORD CHILDREN'S DENTAL CENTER, PC
Other - Org Name:A-OK CHILDREN'S DENTISTRY, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:609-654-1141
Mailing Address - Street 1:1221 N CHURCH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1245
Mailing Address - Country:US
Mailing Address - Phone:856-235-0020
Mailing Address - Fax:
Practice Address - Street 1:520 STOKES RD
Practice Address - Street 2:SUITE B 18
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2904
Practice Address - Country:US
Practice Address - Phone:609-654-1141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty