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General NPI Number Information
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NPI Number | 1083936611
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Entity Type | Organization
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Legal Business Name | LTC MOBILE DENTAL SERVICES, P.A.
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Dates
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Enumeration Date | 02/23/2010
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Last Update Date | 09/01/2011
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Provider Practice Location Address
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Address Line | 1961 MORRIS AVE SUITE A-7
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City | UNION
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State | NJ
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Zip | 07083-3531
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Country | US
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Telephone | 551-404-5769
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Fax | 866-810-8101
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Provider Business Mailing Address
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Address Line | 1961 MORRIS AVE SUITE A-7
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City | UNION
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State | NJ
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Zip | 07083-3531
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Country | US
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Telephone | 551-404-5769
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Fax | 866-810-8101
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RAMA E. GVILDYS
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Credential | DMD
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Telephone | 551-404-5769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02289100
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI01820201
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License Number State | NJ
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