Provider Demographics
NPI:1710552278
Name:CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC
Other - Org Name:CHILDREN'S DENTAL SURGERY OF JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VAN PHI
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-575-2321
Mailing Address - Street 1:300 WILLOWBROOK LN STE 330
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5594
Mailing Address - Country:US
Mailing Address - Phone:267-575-2321
Mailing Address - Fax:
Practice Address - Street 1:27 S COOKS BRIDGE RD STE 2-3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2462
Practice Address - Country:US
Practice Address - Phone:732-928-1099
Practice Address - Fax:732-833-1690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty