Provider Demographics
NPI:1184808743
Name:MEDFORD PERIODONTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:MEDFORD PERIODONTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CALEM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-953-3700
Mailing Address - Street 1:30 JACKSON RD
Mailing Address - Street 2:SUITE A-5
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9283
Mailing Address - Country:US
Mailing Address - Phone:609-953-3700
Mailing Address - Fax:
Practice Address - Street 1:30 JACKSON RD
Practice Address - Street 2:SUITE A-5
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9283
Practice Address - Country:US
Practice Address - Phone:609-953-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI016539001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty