Provider Demographics
NPI:1639155336
Name:LAKEWOOD PEDIATRIC DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LAKEWOOD PEDIATRIC DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIERNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-363-5558
Mailing Address - Street 1:1328 ROUTE 9 SOUTH, SUITE 11 & 12
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5645
Mailing Address - Country:US
Mailing Address - Phone:732-363-5558
Mailing Address - Fax:732-363-5512
Practice Address - Street 1:1328 ROUTE 9 SOUTH, SUITE 11 & 12
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5645
Practice Address - Country:US
Practice Address - Phone:732-363-5558
Practice Address - Fax:732-363-5512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0221X
NJ1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0170682-01Medicaid