MEDICARE: DAVID PODOLNICK D.D.S.

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	22DI01812000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	807715	OTHER	PA	UNITED CONCORDIA PROVIDER
2	0177	OTHER	NJ	DELTA DENTAL PROVIDER ID

General Provider Information

NPI Number	:	1285722785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID PODOLNICK D.D.S.

Provider Business Mailing Address
First Line	:	3932 BLACK HORSE PIKE
Second Line	:
City	:	MAYS LANDING
State	:	NJ
Zip	:	08330-3107
Country	:	US
Telephone Number	:	609-909-1100
Fax Number	:	609-909-9199

Provider Business Practice Location Address
First Line	:	3932 BLACK HORSE PIKE
Second Line	:
City	:	MAYS LANDING
State	:	NJ
Zip	:	08330-3107
Country	:	US
Telephone Number	:	609-909-1100
Fax Number	:	609-909-9199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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