Provider Demographics
NPI:1154437614
Name:FOX MEADOW COSMETIC & FAMILY DENTAL ASSOC PA
Entity type:Organization
Organization Name:FOX MEADOW COSMETIC & FAMILY DENTAL ASSOC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOLLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:AHLUWALIA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-985-1400
Mailing Address - Street 1:108 CENTRE BLVD STE G
Mailing Address - Street 2:SUITE G
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4132
Mailing Address - Country:US
Mailing Address - Phone:856-985-1400
Mailing Address - Fax:856-985-1411
Practice Address - Street 1:108 CENTRE BLVD STE G
Practice Address - Street 2:SUITE G
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4132
Practice Address - Country:US
Practice Address - Phone:856-985-1400
Practice Address - Fax:856-985-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI18977261QD0000X
NJDI16582261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental