Healthcare Provider Details

I. General information

NPI: 1184808743
Provider Name (Legal Business Name): MEDFORD PERIODONTAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 08/13/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JACKSON RD SUITE A-5
MEDFORD NJ
08055-9283
US

IV. Provider business mailing address

30 JACKSON RD SUITE A-5
MEDFORD NJ
08055-9283
US

V. Phone/Fax

Practice location:
  • Phone: 609-953-3700
  • Fax:
Mailing address:
  • Phone: 609-953-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI01653900
License Number StateNJ

VIII. Authorized Official

Name: BERNARD CALEM
Title or Position: OWNER
Credential: DMD
Phone: 609-953-3700