Healthcare Provider Details

I. General information

NPI: 1003677477
Provider Name (Legal Business Name): OLD BRIDGE PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 US HIGHWAY 9 FL 2
OLD BRIDGE NJ
08857-2691
US

IV. Provider business mailing address

3333 US HIGHWAY 9 FL 2
OLD BRIDGE NJ
08857-2691
US

V. Phone/Fax

Practice location:
  • Phone: 732-737-7336
  • Fax:
Mailing address:
  • Phone: 732-737-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LUIS E MARTINEZ
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 732-801-9176