MEDICARE: DENTRUST DENTAL, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22D101759200	OTHER	NJ	LICENSE NUMBER

General Provider Information

NPI Number	:	1023724044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTRUST DENTAL, P.A.

Provider Business Mailing Address
First Line	:	6097 EASTON RD
Second Line	:
City	:	PIPERSVILLE
State	:	PA
Zip	:	18947-1810
Country	:	US
Telephone Number	:	445-200-8197
Fax Number	:

Provider Business Practice Location Address
First Line	:	3452 BRODY AVE
Second Line	:
City	:	FT. DIX
State	:	NJ
Zip	:	08640
Country	:	US
Telephone Number	:	609-342-6467
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	AMANDA A CLARK
Credential	:
Telephone Number	:	609-342-6467

Provider Enumeration Date	:	01/24/2023
Last Update Date	:	01/24/2023

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