Provider Demographics
NPI:1598199101
Name:SOUTH JERSEY PEDIATRIC DENTAL, LLC
Entity Type:Organization
Organization Name:SOUTH JERSEY PEDIATRIC DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDALIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTOL MARTIR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-839-7019
Mailing Address - Street 1:2550 S MAIN RD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-7138
Mailing Address - Country:US
Mailing Address - Phone:856-213-4400
Mailing Address - Fax:856-213-4401
Practice Address - Street 1:2550 S MAIN RD
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7138
Practice Address - Country:US
Practice Address - Phone:856-213-4400
Practice Address - Fax:856-213-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty