MEDICARE: SOUTH JERSEY PERIODONTICS PC

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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1245308444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH JERSEY PERIODONTICS PC

Provider Business Mailing Address
First Line	:	3069 ENGLISH CREEK AVE
Second Line	:	STE 101
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-9708
Country	:	US
Telephone Number	:	609-646-8443
Fax Number	:	609-646-2758

Provider Business Practice Location Address
First Line	:	3069 ENGLISH CREEK AVE
Second Line	:	STE 101
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-9708
Country	:	US
Telephone Number	:	609-646-8443
Fax Number	:	609-646-2758

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NEIL R ZACHS
Credential	:	DMD
Telephone Number	:	609-646-8443

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	09/29/2008

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