Provider Demographics
NPI:1053035576
Name:SOUTH JERSEY DENTAL STUDIO LLC
Entity type:Organization
Organization Name:SOUTH JERSEY DENTAL STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKOONEZHAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-615-8087
Mailing Address - Street 1:539 MARLTON PIKE W
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002
Mailing Address - Country:US
Mailing Address - Phone:856-406-6570
Mailing Address - Fax:
Practice Address - Street 1:539 MARLTON PIKE W
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002
Practice Address - Country:US
Practice Address - Phone:856-406-6570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental