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General NPI Number Information
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NPI Number | 1770971103
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Entity Type | Organization
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Legal Business Name | PEB DENTAL DDS PA
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Dates
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Enumeration Date | 01/08/2015
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Last Update Date | 01/08/2015
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Provider Practice Location Address
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Address Line | 230 ROUTE 18
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-1909
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Country | US
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Telephone | 732-609-9106
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Fax | 732-752-1268
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Provider Business Mailing Address
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Address Line | 230 ROUTE 18
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-1909
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Country | US
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Telephone | 732-609-9106
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Fax | 732-752-1268
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Authorized Official
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Title or Position | PEDIATRICIAN
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Name | DR. VIJAYA RADAKRISHNA
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Credential | M.D.
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Telephone | 732-752-1932
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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 | 0101028295
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License Number State | NJ
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