=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104009943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTISTRY OF SOUTH JERSEY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2007
-----------------------------------------------------
Last Update Date | 12/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3071 E CHESTNUT AVE SUITE D-10
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08361-7847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-205-0099
-----------------------------------------------------
Fax | 856-205-1633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3071 E CHESTNUT AVE SUITE D-10
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08361-7847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-205-0099
-----------------------------------------------------
Fax | 856-205-1633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM R BECK
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 856-205-0099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DI16646
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------