=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790029031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIANCE DENTAL SPECIALTIES OF MANAHAWKIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2012
-----------------------------------------------------
Last Update Date | 11/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 ROUTE 72 EAST SUITE 220
-----------------------------------------------------
City | MANAHAWKIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08050-2483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-978-6400
-----------------------------------------------------
Fax | 732-842-5910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 NEWMAN SPRINGS RD
-----------------------------------------------------
City | LINCROFT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07738-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-842-5915
-----------------------------------------------------
Fax | 732-842-5910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN FRATTELLONE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 732-842-5915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 16514
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------