Provider Demographics
NPI:1821491317
Name:SOUTHJERSEYDENTISTRY LLC
Entity Type:Organization
Organization Name:SOUTHJERSEYDENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-240-0406
Mailing Address - Street 1:368 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08009-1954
Mailing Address - Country:US
Mailing Address - Phone:856-240-0406
Mailing Address - Fax:
Practice Address - Street 1:368 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-1954
Practice Address - Country:US
Practice Address - Phone:856-240-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02287500261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental