Provider Demographics
NPI:1679811129
Name:HOLDBROOK PEDIATRIC DENTAL, LLC
Entity Type:Organization
Organization Name:HOLDBROOK PEDIATRIC DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-783-0444
Mailing Address - Street 1:250 HADDONFIELD BERLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GIBBSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08026-1228
Mailing Address - Country:US
Mailing Address - Phone:856-783-0444
Mailing Address - Fax:856-241-1251
Practice Address - Street 1:553 BECKETT RD
Practice Address - Street 2:SUITE 604
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1565
Practice Address - Country:US
Practice Address - Phone:856-556-4020
Practice Address - Fax:856-241-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024453001223G0001X
NJ22DI022982001223P0221X
NJ22DI024638001223P0221X
NJ22DI023795001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0212768Medicaid