Provider Demographics
NPI:1447379102
Name:NEW JERSEY MOBILE DENTAL PRACTICE, P.A.
Entity Type:Organization
Organization Name:NEW JERSEY MOBILE DENTAL PRACTICE, P.A.
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:732-431-7577
Mailing Address - Street 1:637 WYCKOFF AVE
Mailing Address - Street 2:SUITE 236
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1438
Mailing Address - Country:US
Mailing Address - Phone:732-431-7577
Mailing Address - Fax:732-431-8070
Practice Address - Street 1:24 MERCHANTS WAY
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-1570
Practice Address - Country:US
Practice Address - Phone:732-431-7577
Practice Address - Fax:732-431-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI018346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6516301Medicaid