Provider Demographics
NPI:1821412800
Name:ADDIEGO FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:ADDIEGO FAMILY DENTAL LLC
Other - Org Name:CEDAR CREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:BRAMLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-489-3360
Mailing Address - Street 1:950 ATLANTIC CITY BLVD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-3564
Mailing Address - Country:US
Mailing Address - Phone:732-269-1046
Mailing Address - Fax:
Practice Address - Street 1:950 ATLANTIC CITY BLVD
Practice Address - Street 2:SUITE 13
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-3564
Practice Address - Country:US
Practice Address - Phone:732-269-1046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI021078001223G0001X
NJ22DI023283001223G0001X
NJ22DI009710001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty