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General NPI Number Information
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NPI Number | 1598199101
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Entity Type | Organization
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Legal Business Name | SOUTH JERSEY PEDIATRIC DENTAL, LLC
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Dates
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Enumeration Date | 08/30/2013
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Last Update Date | 05/06/2022
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Provider Practice Location Address
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Address Line | 2550 S MAIN RD
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City | VINELAND
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State | NJ
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Zip | 08360-7138
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Country | US
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Telephone | 856-213-4400
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Fax | 856-213-4401
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Provider Business Mailing Address
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Address Line | 2550 S MAIN RD
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City | VINELAND
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State | NJ
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Zip | 08360-7138
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Country | US
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Telephone | 856-213-4400
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Fax | 856-213-4401
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. BRENDALIZ BRISTOL MARTIR
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Credential | D.M.D.
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Telephone | 856-839-7019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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