Healthcare Provider Details

I. General information

NPI: 1942977491
Provider Name (Legal Business Name): NJ DFC ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 RIVER AVE
LAKEWOOD NJ
08701-5280
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 484-787-2946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

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