Healthcare Provider Details

I. General information

NPI: 1780474494
Provider Name (Legal Business Name): RIVERSIDE PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JACKSON RD STE B2
MEDFORD NJ
08055-9280
US

IV. Provider business mailing address

757 WESTFIELD RD
MOORESTOWN NJ
08057-2139
US

V. Phone/Fax

Practice location:
  • Phone: 609-947-3526
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHLEY LEBAK
Title or Position: PEDIATRIC DENTIST
Credential: DMD
Phone: 609-947-3526