MEDICARE: SOUTH PLAINFIELD ORTHODONTICS, LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DI17700	NJ

General Provider Information

NPI Number	:	1578639712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PLAINFIELD ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	1904 PARK AVE
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-5524
Country	:	US
Telephone Number	:	908-756-5468
Fax Number	:	908-756-7469

Provider Business Practice Location Address
First Line	:	1904 PARK AVE
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-5524
Country	:	US
Telephone Number	:	908-756-5468
Fax Number	:	908-756-7469

Authorized Official
Title or Position	:	SOLE MBR
Name	:	DR. CRAIG MENKER
Credential	:	DMD
Telephone Number	:	908-756-5468

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	08/22/2020

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