Provider Demographics
NPI:1356413777
Name:SENIOR CARE DENTAL
Entity type:Organization
Organization Name:SENIOR CARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-446-0620
Mailing Address - Street 1:93 HOME PLACE
Mailing Address - Street 2:1ST FL
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644
Mailing Address - Country:US
Mailing Address - Phone:973-446-0620
Mailing Address - Fax:973-446-0620
Practice Address - Street 1:345 PASSAIC AVE
Practice Address - Street 2:1ST FL
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644
Practice Address - Country:US
Practice Address - Phone:973-446-0620
Practice Address - Fax:973-446-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0014931Medicaid