Provider Demographics
NPI:1881735702
Name:STUART A WASSERLAUF DDS PA
Entity type:Organization
Organization Name:STUART A WASSERLAUF DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KASH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-848-2211
Mailing Address - Street 1:776 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08086
Mailing Address - Country:US
Mailing Address - Phone:856-848-2211
Mailing Address - Fax:856-848-8630
Practice Address - Street 1:776 GROVE RD
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08086
Practice Address - Country:US
Practice Address - Phone:856-848-2211
Practice Address - Fax:856-848-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2618605Medicaid