Provider Demographics
NPI:1992891865
Name:LONG BRANCH DENTAL CENTER
Entity type:Organization
Organization Name:LONG BRANCH DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:F
Authorized Official - Last Name:MORALES MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-229-4434
Mailing Address - Street 1:9 MEMORIAL PKWY
Mailing Address - Street 2:SECOND FLOOR A
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6701
Mailing Address - Country:US
Mailing Address - Phone:732-229-4434
Mailing Address - Fax:732-229-4476
Practice Address - Street 1:9 MEMORIAL PKWY
Practice Address - Street 2:SECOND FLOOR A
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6701
Practice Address - Country:US
Practice Address - Phone:732-229-4434
Practice Address - Fax:732-229-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19674261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental