Provider Demographics
NPI:1508104654
Name:WEST ORANGE DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WEST ORANGE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEJUMADE
Authorized Official - Middle Name:
Authorized Official - Last Name:ST MATTHEW-DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:409-290-9588
Mailing Address - Street 1:217 N KIRKMAN RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1186
Mailing Address - Country:US
Mailing Address - Phone:407-290-9588
Mailing Address - Fax:
Practice Address - Street 1:217 N KIRKMAN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-1186
Practice Address - Country:US
Practice Address - Phone:407-290-9588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16856302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization