Provider Demographics
NPI:1770316382
Name:LUMINA DENTAL SERVICES LLC
Entity type:Organization
Organization Name:LUMINA DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:LARISA
Authorized Official - Last Name:MACIEJESKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-600-3964
Mailing Address - Street 1:2412 CHESTNUT HILL DR
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3623
Mailing Address - Country:US
Mailing Address - Phone:702-600-3964
Mailing Address - Fax:
Practice Address - Street 1:105 MEDFORD-EVESBORO RD B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental