Provider Demographics
NPI:1174697973
Name:SOUTH JERSEY PROSTHODONTIC ASSOC. PA
Entity type:Organization
Organization Name:SOUTH JERSEY PROSTHODONTIC ASSOC. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-424-7177
Mailing Address - Street 1:1793 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2136
Mailing Address - Country:US
Mailing Address - Phone:856-424-7177
Mailing Address - Fax:856-424-0896
Practice Address - Street 1:1793 SPRINGDALE RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2136
Practice Address - Country:US
Practice Address - Phone:856-424-7177
Practice Address - Fax:856-424-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2965402Medicaid
NJ077832Medicare PIN
NJ0371110001Medicare NSC