Provider Demographics
NPI:1548962863
Name:PS DENTAL DC 1, P.C.
Entity type:Organization
Organization Name:PS DENTAL DC 1, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:732-731-8398
Mailing Address - Street 1:1144 HOOPER AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8361
Mailing Address - Country:US
Mailing Address - Phone:732-731-8398
Mailing Address - Fax:
Practice Address - Street 1:4740 CONNECTICUT AVE NW APT 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-5604
Practice Address - Country:US
Practice Address - Phone:410-761-0095
Practice Address - Fax:202-364-3274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSMILE HOLDING II LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-20
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty