Healthcare Provider Details

I. General information

NPI: 1225563877
Provider Name (Legal Business Name): DIAMOND BEACH DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 PACIFIC AVE
WILDWOOD CREST NJ
08260-3213
US

IV. Provider business mailing address

9850 PACIFIC AVE
WILDWOOD CREST NJ
08260-3213
US

V. Phone/Fax

Practice location:
  • Phone: 609-522-3145
  • Fax: 609-522-9008
Mailing address:
  • Phone: 609-522-3145
  • Fax: 609-522-9008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDI12756
License Number StateNJ

VIII. Authorized Official

Name: DR. SCOTT MASLOW
Title or Position: PRESIDENT
Credential: DMD
Phone: 609-522-3145