=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821455502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEY DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2016
-----------------------------------------------------
Last Update Date | 01/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 MOUNT HOLLY RD SUITE 2C
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08016-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-835-4043
-----------------------------------------------------
Fax | 609-835-1576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 MOUNT HOLLY RD SUITE 2C
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08016-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-835-4043
-----------------------------------------------------
Fax | 609-835-1576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. MIR RASHID ALIKHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-835-4043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02624000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02383100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI01354000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------