=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184845604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEPTUNE FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 STATE ROUTE 33
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-4362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-774-0077
-----------------------------------------------------
Fax | 732-988-1176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 STATE ROUTE 33
-----------------------------------------------------
City | NEPTUNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07753-4362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-774-0077
-----------------------------------------------------
Fax | 732-988-1176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA R JIMENEZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 732-774-0077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI02193300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------