=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083775977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE DAYSPRING CENTER FOR LASER DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 188 FRIES MILL ROAD SUITE E2
-----------------------------------------------------
City | TURNERSVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-875-8400
-----------------------------------------------------
Fax | 856-875-5329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 188 FRIES MILL ROAD SUITE E2
-----------------------------------------------------
City | TURNERSVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-875-8400
-----------------------------------------------------
Fax | 856-875-5329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | MATTHEW F BICKEL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 856-875-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DI18611
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DI18737
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------