Provider Demographics
NPI:1528370269
Name:GENESIS FAMILY DENTAL
Entity Type:Organization
Organization Name:GENESIS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MPH
Authorized Official - Phone:856-541-3627
Mailing Address - Street 1:1436 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3111
Mailing Address - Country:US
Mailing Address - Phone:856-541-3627
Mailing Address - Fax:856-541-1622
Practice Address - Street 1:1436 HADDON AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3111
Practice Address - Country:US
Practice Address - Phone:856-541-3627
Practice Address - Fax:856-541-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty