Healthcare Provider Details

I. General information

NPI: 1205074457
Provider Name (Legal Business Name): JERSEY SHORE DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 CORLIES AVE SUITE 8
NEPTUNE NJ
07755
US

IV. Provider business mailing address

1820 CORLIES AVE SUITE 8
NEPTUNE NJ
07755
US

V. Phone/Fax

Practice location:
  • Phone: 732-774-5772
  • Fax:
Mailing address:
  • Phone: 732-774-5772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDI 21284
License Number StateNJ

VIII. Authorized Official

Name: DR. KHALED ELDIN
Title or Position: PRISEDENT
Credential: DDS
Phone: 732-774-5772