Provider Demographics
NPI:1205453032
Name:DENTAL OF CLEMENTON
Entity type:Organization
Organization Name:DENTAL OF CLEMENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-783-3300
Mailing Address - Street 1:250 GIBBSBORO RD
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-4130
Mailing Address - Country:US
Mailing Address - Phone:856-783-3300
Mailing Address - Fax:
Practice Address - Street 1:250 GIBBSBORO RD
Practice Address - Street 2:
Practice Address - City:CLEMENTON
Practice Address - State:NJ
Practice Address - Zip Code:08021-4130
Practice Address - Country:US
Practice Address - Phone:856-783-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty