Healthcare Provider Details

I. General information

NPI: 1740344860
Provider Name (Legal Business Name): PENNINGTON DENTAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 NORTH MAIN STREET
PENNINGTON NJ
08534
US

IV. Provider business mailing address

31 NORTH MAIN STREET
PENNINGTON NJ
08534
US

V. Phone/Fax

Practice location:
  • Phone: 609-737-0288
  • Fax: 609-737-7088
Mailing address:
  • Phone: 609-737-0288
  • Fax: 609-737-7088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22D100961500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID H GOODMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 609-737-0288