=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518115377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUMBERLAND PERIODONTAL ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2008
-----------------------------------------------------
Last Update Date | 09/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1077 E. CHESTNUT AVE.
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-696-3990
-----------------------------------------------------
Fax | 856-696-2121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1077 E. CHESTNUT AVE.
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-696-3990
-----------------------------------------------------
Fax | 856-696-2121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARC DAVID STEIN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 856-696-3990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2068
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | NJ11102
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------