Provider Demographics
NPI:1851310148
Name:ADVANCED DENTISTRY OF JACKSON, LLC
Entity Type:Organization
Organization Name:ADVANCED DENTISTRY OF JACKSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-363-1331
Mailing Address - Street 1:2121 W COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2357
Mailing Address - Country:US
Mailing Address - Phone:732-363-1331
Mailing Address - Fax:
Practice Address - Street 1:2121 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2357
Practice Address - Country:US
Practice Address - Phone:732-363-1331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI217011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDI21701OtherLICENSE NUMBER
NJDI21701OtherLICENSE NUMBER