Provider Demographics
NPI:1982743944
Name:BARRY E ETTELSON DDS PA
Entity Type:Organization
Organization Name:BARRY E ETTELSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETTELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-227-2554
Mailing Address - Street 1:900 ROUTE 168 STE I6
Mailing Address - Street 2:WASHINGTON PROFESSIONAL CAMPUS
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3212
Mailing Address - Country:US
Mailing Address - Phone:856-227-2554
Mailing Address - Fax:856-227-4066
Practice Address - Street 1:900 ROUTE 168 STE I6
Practice Address - Street 2:WASHINGTON PROFESSIONAL CAMPUS
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-3212
Practice Address - Country:US
Practice Address - Phone:856-227-2554
Practice Address - Fax:856-227-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ084241223G0001X
PAD5015997L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty