Provider Demographics
NPI:1760006209
Name:SOUTH JERSEY CENTER FOR ADVANCED DENTISTRY, LLC
Entity Type:Organization
Organization Name:SOUTH JERSEY CENTER FOR ADVANCED DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LADERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-988-7773
Mailing Address - Street 1:20 BOX TURTLE LN
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5682
Mailing Address - Country:US
Mailing Address - Phone:973-202-0266
Mailing Address - Fax:
Practice Address - Street 1:750 ROUTE 73 S STE 209
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4133
Practice Address - Country:US
Practice Address - Phone:856-988-7773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty