Healthcare Provider Details

I. General information

NPI: 1558936567
Provider Name (Legal Business Name): OAKWOOD DENTAL ADULT AND PEDIATRIC CARE OF OLD BRIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3689 U.S. 9
OLD BRIDGE NJ
08857
US

IV. Provider business mailing address

3689 U.S. 9
OLD BRIDGE NJ
08857
US

V. Phone/Fax

Practice location:
  • Phone: 732-401-3131
  • Fax:
Mailing address:
  • Phone:
  • 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: TONILYNN EGAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 718-979-2121