Provider Demographics
NPI:1700919594
Name:WOODBINE DENTAL PA
Entity Type:Organization
Organization Name:WOODBINE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUES
Authorized Official - Middle Name:
Authorized Official - Last Name:NATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:609-861-2784
Mailing Address - Street 1:901 DEHIRSCH AVENUE
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08270
Mailing Address - Country:US
Mailing Address - Phone:609-861-2784
Mailing Address - Fax:609-861-3160
Practice Address - Street 1:901 DEHIRSCH AVENUE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:NJ
Practice Address - Zip Code:08270
Practice Address - Country:US
Practice Address - Phone:609-861-2784
Practice Address - Fax:609-861-3160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI00879400122300000X
NJ22DI01877400122300000X
NJ22DI01862600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2743906Medicaid