Provider Demographics
NPI:1295112043
Name:KOOL KOALA PEDIATRIC AND ADOLESCENT DENTISTRY
Entity type:Organization
Organization Name:KOOL KOALA PEDIATRIC AND ADOLESCENT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-230-0924
Mailing Address - Street 1:501 WHITEHORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08107
Mailing Address - Country:US
Mailing Address - Phone:856-230-0924
Mailing Address - Fax:
Practice Address - Street 1:501 WHITEHORSE PIKE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08107
Practice Address - Country:US
Practice Address - Phone:856-230-0924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO24475031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty