Provider Demographics
NPI:1871054940
Name:TRI-STATE DENTISTRY DEH, LLC
Entity type:Organization
Organization Name:TRI-STATE DENTISTRY DEH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMIK
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-418-5436
Mailing Address - Street 1:6801 BLACK HORSE PIKE STE 100
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-4120
Mailing Address - Country:US
Mailing Address - Phone:856-418-5436
Mailing Address - Fax:
Practice Address - Street 1:6801 BLACK HORSE PIKE STE 1000
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-4115
Practice Address - Country:US
Practice Address - Phone:856-418-5436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-STATE DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental