Provider Demographics
NPI:1760800346
Name:PENNS GROVE FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:PENNS GROVE FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SYLVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARFUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-299-1096
Mailing Address - Street 1:31 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PENNS GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08069-1348
Mailing Address - Country:US
Mailing Address - Phone:856-299-1096
Mailing Address - Fax:
Practice Address - Street 1:31 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PENNS GROVE
Practice Address - State:NJ
Practice Address - Zip Code:08069-1348
Practice Address - Country:US
Practice Address - Phone:856-299-1096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicaid