Healthcare Provider Details

I. General information

NPI: 1447272562
Provider Name (Legal Business Name): SOUTH JERSEY ORAL & MAXILLOFACIAL SURGEONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 JACKSON RD SUITE A
MEDFORD NJ
08055-9231
US

IV. Provider business mailing address

135 JACKSON RD SUITE A
MEDFORD NJ
08055-9231
US

V. Phone/Fax

Practice location:
  • Phone: 609-654-1300
  • Fax: 609-654-0040
Mailing address:
  • Phone: 609-654-1300
  • Fax: 609-654-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. AMERIGO FEDELI
Title or Position: DOCTOR
Credential: DMD
Phone: 609-654-1300