Provider Demographics
NPI:1851109037
Name:HALEDON DENTAL SPA LLC
Entity type:Organization
Organization Name:HALEDON DENTAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BODRATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-432-2909
Mailing Address - Street 1:4 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-3520
Mailing Address - Country:US
Mailing Address - Phone:973-432-2909
Mailing Address - Fax:
Practice Address - Street 1:397 HALEDON AVE
Practice Address - Street 2:
Practice Address - City:HALEDON
Practice Address - State:NJ
Practice Address - Zip Code:07508-1551
Practice Address - Country:US
Practice Address - Phone:973-995-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty