Provider Demographics
NPI:1700046216
Name:BRADEN DENTAL OF SOUTH JERSEY PC
Entity type:Organization
Organization Name:BRADEN DENTAL OF SOUTH JERSEY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,
Authorized Official - Phone:609-560-5902
Mailing Address - Street 1:640 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3145
Mailing Address - Country:US
Mailing Address - Phone:856-845-4225
Mailing Address - Fax:856-845-4221
Practice Address - Street 1:640 KINGS HWY
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3145
Practice Address - Country:US
Practice Address - Phone:856-845-4225
Practice Address - Fax:856-845-4221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADEN DENTAL OF SOUTH JERSEY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-10
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI021527001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty