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General NPI Number Information
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NPI Number | 1780474494
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Entity Type | Organization
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Legal Business Name | RIVERSIDE PEDIATRIC DENTISTRY AND ORTHODONTICS
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 10/20/2025
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Provider Practice Location Address
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Address Line | 30 JACKSON RD STE B2
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City | MEDFORD
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State | NJ
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Zip | 08055-9280
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Country | US
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Telephone | 609-947-3526
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Fax |
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Provider Business Mailing Address
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Address Line | 757 WESTFIELD RD
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City | MOORESTOWN
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State | NJ
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Zip | 08057-2139
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. ASHLEY LEBAK
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Credential | DMD
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Telephone | 609-947-3526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics 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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