MEDICARE: DENTAL CARE OF EGG HARBOR

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1104499888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL CARE OF EGG HARBOR

Provider Business Mailing Address
First Line	:	1500 S LINCOLN AVE
Second Line	:
City	:	VINELAND
State	:	NJ
Zip	:	08361-6610
Country	:	US
Telephone Number	:	856-691-2307
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 PHILADELPHIA AVE UNIT 207
Second Line	:
City	:	EGG HARBOR CITY
State	:	NJ
Zip	:	08215-1330
Country	:	US
Telephone Number	:	856-691-2307
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FRANK PETTISANI JR.
Credential	:	DDS
Telephone Number	:	856-691-2307

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	07/21/2021

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