Provider Demographics
NPI:1689261554
Name:NU DENTAL OF BARNEGAT
Entity Type:Organization
Organization Name:NU DENTAL OF BARNEGAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADMASU
Authorized Official - Middle Name:N
Authorized Official - Last Name:GIZACHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:609-879-0036
Mailing Address - Street 1:16 RIVERSIDE LN
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2084
Mailing Address - Country:US
Mailing Address - Phone:732-945-7999
Mailing Address - Fax:
Practice Address - Street 1:770 LIGHTHOUSE DR # 192-B
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-2373
Practice Address - Country:US
Practice Address - Phone:609-879-0036
Practice Address - Fax:609-879-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0440833Medicaid