MEDICARE: DDSCNJ LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1003408402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DDSCNJ LLC

Provider Business Mailing Address
First Line	:	3001 STATE ROUTE 27 STE 1
Second Line	:
City	:	FRANKLIN PARK
State	:	NJ
Zip	:	08823-1229
Country	:	US
Telephone Number	:	848-213-5445
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 STATE ROUTE 27 STE 1
Second Line	:
City	:	FRANKLIN PARK
State	:	NJ
Zip	:	08823-1229
Country	:	US
Telephone Number	:	848-213-5445
Fax Number	:	848-900-8042

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MICHEL AETIA
Credential	:
Telephone Number	:	732-688-7854

Provider Enumeration Date	:	02/07/2021
Last Update Date	:	04/25/2024

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