Provider Demographics
NPI:1295582005
Name:LITTLE SMILES PEDIATRIC DENTISTRY OF SOUTH JERSEY
Entity type:Organization
Organization Name:LITTLE SMILES PEDIATRIC DENTISTRY OF SOUTH JERSEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/AR
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-207-8406
Mailing Address - Street 1:1206 W SHERMAN AVE STE 4D
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6911
Mailing Address - Country:US
Mailing Address - Phone:856-368-2800
Mailing Address - Fax:856-412-5100
Practice Address - Street 1:1206 W SHERMAN AVE STE 4D
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6911
Practice Address - Country:US
Practice Address - Phone:856-368-2800
Practice Address - Fax:856-412-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ06371-03OtherSPECIALTY PERMIT
NJ0490644Medicaid
NJ22DI02457700OtherDENTAL LICENSE