=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457566739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES J TENBROOK DMD, MMSC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 N HIGH ST
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-1922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-413-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 DEER PATH RD
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-413-3027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3828
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------