Provider Demographics
NPI:1568526291
Name:BRIDGE FAMILY DENTAL GRP PA
Entity Type:Organization
Organization Name:BRIDGE FAMILY DENTAL GRP PA
Other - Org Name:CHARLES D LOTT DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-782-4418
Mailing Address - Street 1:820 RTE 202 N
Mailing Address - Street 2:
Mailing Address - City:NESHANIC STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:08853
Mailing Address - Country:US
Mailing Address - Phone:908-782-4418
Mailing Address - Fax:908-782-8661
Practice Address - Street 1:15 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2110
Practice Address - Country:US
Practice Address - Phone:908-725-0400
Practice Address - Fax:908-725-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1009270 01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1904906Medicaid