Healthcare Provider Details

I. General information

NPI: 1144595356
Provider Name (Legal Business Name): ADVANCED DENTAL OF WOOLWICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 RT 322 SUITE F
WOOLWICH NJ
08085
US

IV. Provider business mailing address

1630 RT 322 SUITE F
WOOLWICH NJ
08085
US

V. Phone/Fax

Practice location:
  • Phone: 856-832-4480
  • Fax:
Mailing address:
  • Phone: 856-832-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DIO2146400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number22DIO2196800
License Number StateNJ

VIII. Authorized Official

Name: DR. LADERRICK BULLOCK
Title or Position: OWNER
Credential:
Phone: 856-832-4480