MEDICARE: TRI-STATE DENTISTRY DEH, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1871054940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE DENTISTRY DEH, LLC

Provider Business Mailing Address
First Line	:	6801 BLACK HORSE PIKE STE 100
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-4120
Country	:	US
Telephone Number	:	856-418-5436
Fax Number	:

Provider Business Practice Location Address
First Line	:	6801 BLACK HORSE PIKE STE 1000
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-4115
Country	:	US
Telephone Number	:	856-418-5436
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	SHAMIK DESAI
Credential	:
Telephone Number	:	856-418-5436

Provider Enumeration Date	:	03/29/2019
Last Update Date	:	03/29/2019

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