Provider Demographics
NPI:1982003315
Name:OLD BRIDGE DENTAL ARTS
Entity Type:Organization
Organization Name:OLD BRIDGE DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MORDECAI
Authorized Official - Middle Name:
Authorized Official - Last Name:LIECHTUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-257-5600
Mailing Address - Street 1:30 STATE HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857
Mailing Address - Country:US
Mailing Address - Phone:732-257-5600
Mailing Address - Fax:732-651-1454
Practice Address - Street 1:30 STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857
Practice Address - Country:US
Practice Address - Phone:732-257-5600
Practice Address - Fax:732-651-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization