Healthcare Provider Details

I. General information

NPI: 1326700923
Provider Name (Legal Business Name): CHILDREN'S DENTAL SURGERY CENTER OF JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 S COOKS BRIDGE RD STE L-2
JACKSON NJ
08527-2461
US

IV. Provider business mailing address

300 WILLOWBROOK LN STE 330
WEST CHESTER PA
19382-5594
US

V. Phone/Fax

Practice location:
  • Phone: 732-928-1099
  • Fax:
Mailing address:
  • Phone: 267-575-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PHI LE
Title or Position: CREDENTIALING CONTRACTS MANAGER
Credential:
Phone: 267-575-2321