Provider Demographics
NPI:1528207198
Name:DEPTFORD FAMILY DENTAL PA
Entity Type:Organization
Organization Name:DEPTFORD FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-914-1039
Mailing Address - Street 1:2000 CLEMENTS BRIDGE RD
Mailing Address - Street 2:SUITE 117 A
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2011
Mailing Address - Country:US
Mailing Address - Phone:856-848-6006
Mailing Address - Fax:856-848-6969
Practice Address - Street 1:2000 CLEMENTS BRIDGE RD
Practice Address - Street 2:SUITE 117 A
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-2011
Practice Address - Country:US
Practice Address - Phone:856-848-6006
Practice Address - Fax:856-848-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty