Provider Demographics
NPI:1720236607
Name:CEDAR RUN ORTHODONTICS, PA
Entity type:Organization
Organization Name:CEDAR RUN ORTHODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEFELICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-978-4411
Mailing Address - Street 1:1064 S MAIN ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:WEST CREEK
Mailing Address - State:NJ
Mailing Address - Zip Code:08092-2912
Mailing Address - Country:US
Mailing Address - Phone:609-978-4411
Mailing Address - Fax:609-978-6677
Practice Address - Street 1:1064 S MAIN ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:WEST CREEK
Practice Address - State:NJ
Practice Address - Zip Code:08092-2912
Practice Address - Country:US
Practice Address - Phone:609-978-4411
Practice Address - Fax:609-978-6677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022781001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty