Provider Demographics
NPI:1982389359
Name:KLDDMD1PC
Entity type:Organization
Organization Name:KLDDMD1PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:DEBRA
Authorized Official - Last Name:BAALS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:856-467-1900
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-0128
Mailing Address - Country:US
Mailing Address - Phone:856-467-1900
Mailing Address - Fax:856-467-8435
Practice Address - Street 1:1908 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1638
Practice Address - Country:US
Practice Address - Phone:856-467-1900
Practice Address - Fax:856-467-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty