Provider Demographics
NPI:1023169273
Name:FEDERICI DENTAL PA
Entity type:Organization
Organization Name:FEDERICI DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FEDERICI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-597-1234
Mailing Address - Street 1:1301 ROUTE 72 W
Mailing Address - Street 2:UNIT 230
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2417
Mailing Address - Country:US
Mailing Address - Phone:609-597-1234
Mailing Address - Fax:
Practice Address - Street 1:1301 ROUTE 72 W
Practice Address - Street 2:UNIT 230
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2417
Practice Address - Country:US
Practice Address - Phone:609-597-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty