Provider Demographics
NPI:1023857000
Name:BRADEN DENTAL OF SOUTH JERSEY PC
Entity type:Organization
Organization Name:BRADEN DENTAL OF SOUTH JERSEY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-560-5902
Mailing Address - Street 1:438 GANTTOWN RD STE B
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2341
Mailing Address - Country:US
Mailing Address - Phone:856-589-4300
Mailing Address - Fax:
Practice Address - Street 1:438 GANTTOWN RD STE B
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2341
Practice Address - Country:US
Practice Address - Phone:856-589-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADEN DENTAL OF SOUTH JERSEY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty