Provider Demographics
NPI:1235311028
Name:MOBILE DENTAL PRACTICE, PC
Entity Type:Organization
Organization Name:MOBILE DENTAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-891-4700
Mailing Address - Street 1:800 WYCKOFF AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1525
Mailing Address - Country:US
Mailing Address - Phone:201-891-4700
Mailing Address - Fax:201-891-4943
Practice Address - Street 1:800 WYCKOFF AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1525
Practice Address - Country:US
Practice Address - Phone:201-891-4700
Practice Address - Fax:201-891-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0183461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0090911Medicaid