Provider Demographics
NPI:1619722469
Name:BRADEN DENTAL OF SOUTH JERSEY PC
Entity Type:Organization
Organization Name:BRADEN DENTAL OF SOUTH JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-854-0146
Mailing Address - Street 1:326 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2825
Mailing Address - Country:US
Mailing Address - Phone:609-560-5902
Mailing Address - Fax:
Practice Address - Street 1:160 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-2220
Practice Address - Country:US
Practice Address - Phone:856-678-5124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADEN DENTAL OF SOUTH JERSEY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty