=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760006209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH JERSEY CENTER FOR ADVANCED DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2020
-----------------------------------------------------
Last Update Date | 06/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 ROUTE 73 S STE 209
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-988-7773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 BOX TURTLE LN
-----------------------------------------------------
City | SICKLERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08081-5682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-202-0266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LADERRICK BULLOCK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 856-988-7773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------