=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265722490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSHINE DENTAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2011
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 MIDDLETOWN LINCROFT RD
-----------------------------------------------------
City | LINCROFT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07738-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-842-5005
-----------------------------------------------------
Fax | 732-842-8608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 MIDDLETOWN LINCROFT RD
-----------------------------------------------------
City | LINCROFT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07738-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-842-5005
-----------------------------------------------------
Fax | 732-842-8608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | RICHARD J. MERCURIO
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 732-842-5005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 22DI01142300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------