Healthcare Provider Details

I. General information

NPI: 1659592921
Provider Name (Legal Business Name): PATERNO ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MT LAUREL RD
MT LAUREL NJ
08054
US

IV. Provider business mailing address

501 MT LAUREL RD
MT LAUREL NJ
08054
US

V. Phone/Fax

Practice location:
  • Phone: 856-722-5664
  • Fax: 856-722-5198
Mailing address:
  • Phone: 856-722-5664
  • Fax: 856-722-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI01753000
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHELE PATERNO
Title or Position: LLC PRINCIPAL OWNER
Credential: DMD MSD
Phone: 856-722-5664