Provider Demographics
NPI:1780474494
Name:RIVERSIDE PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity type:Organization
Organization Name:RIVERSIDE PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-947-3526
Mailing Address - Street 1:757 WESTFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-2139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 E SCOTT ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:NJ
Practice Address - Zip Code:08075-3620
Practice Address - Country:US
Practice Address - Phone:609-947-3526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty