Provider Demographics
NPI: | 1790367431 |
---|---|
Name: | COBBLESTONE KIDS PEDIATRIC DENTISTRY OF NEW JERSEY |
Entity Type: | Organization |
Organization Name: | COBBLESTONE KIDS PEDIATRIC DENTISTRY OF NEW JERSEY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR OF OPERATIONS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KATE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MELIDOSIAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MHA, MHRM |
Authorized Official - Phone: | 267-909-9551 |
Mailing Address - Street 1: | 1352 SOUTH ST STE C4 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19147-1858 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 267-909-9551 |
Mailing Address - Fax: | 267-909-9761 |
Practice Address - Street 1: | 17 W ORMOND AVE |
Practice Address - Street 2: | |
Practice Address - City: | CHERRY HILL |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08002-3041 |
Practice Address - Country: | US |
Practice Address - Phone: | 856-288-1929 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-04-22 |
Last Update Date: | 2021-04-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Single Specialty |