Provider Demographics
NPI:1730392630
Name:BERKELEY PERIODONTICS LLC
Entity type:Organization
Organization Name:BERKELEY PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-464-5630
Mailing Address - Street 1:576 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-1055
Mailing Address - Country:US
Mailing Address - Phone:908-464-5630
Mailing Address - Fax:908-464-6297
Practice Address - Street 1:576 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-1055
Practice Address - Country:US
Practice Address - Phone:908-464-5630
Practice Address - Fax:908-464-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI193271223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty