Provider Demographics
NPI:1295264521
Name:MAIN STREET DENTAL - MULLICA HILL
Entity type:Organization
Organization Name:MAIN STREET DENTAL - MULLICA HILL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-223-0041
Mailing Address - Street 1:1030 SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WHEATLEY BLVD
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-9622
Practice Address - Country:US
Practice Address - Phone:856-223-0041
Practice Address - Fax:856-223-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty