Healthcare Provider Details

I. General information

NPI: 1932893039
Provider Name (Legal Business Name): SULLIVAN DARJI DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JACKSON RD STE B1
MEDFORD LAKES NJ
08055-9280
US

IV. Provider business mailing address

30 JACKSON RD STE B1
MEDFORD LAKES NJ
08055-9280
US

V. Phone/Fax

Practice location:
  • Phone: 609-953-0077
  • Fax:
Mailing address:
  • Phone: 609-953-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: RAJ DARJI
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 609-953-0077