Healthcare Provider Details

I. General information

NPI: 1659612158
Provider Name (Legal Business Name): ATLANTIC ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E. JIMMIE LEEDS ROAD
GALLOWAY NJ
08205
US

IV. Provider business mailing address

235 E. JIMMIE LEEDS ROAD
GALLOWAY NJ
08205
US

V. Phone/Fax

Practice location:
  • Phone: 609-568-6415
  • Fax: 609-568-6413
Mailing address:
  • Phone: 609-568-6415
  • Fax: 609-568-6413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: NEHA SHAH
Title or Position: OWNER
Credential: DMD
Phone: 609-568-6415