Provider Demographics
NPI:1710491626
Name:MARLTON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:MARLTON FAMILY DENTISTRY LLC
Other - Org Name:STATE OF THE ART SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENTRALGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-851-6064
Mailing Address - Street 1:560A LIPPINCOTT DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-985-1800
Mailing Address - Fax:856-985-7170
Practice Address - Street 1:560A LIPPINCOTT DR BLDG B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-1800
Practice Address - Fax:856-985-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02666400261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental