Provider Demographics
NPI:1336506849
Name:MAIN STREET FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:MAIN STREET FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-953-7199
Mailing Address - Street 1:76 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2720
Mailing Address - Country:US
Mailing Address - Phone:609-953-7199
Mailing Address - Fax:
Practice Address - Street 1:76 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2720
Practice Address - Country:US
Practice Address - Phone:609-953-7199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ161521223G0001X
165111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty