MEDICARE: DR. BRYON ERNEST ROSHONG DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	22DI00996200	NJ

General Provider Information

NPI Number	:	1023012598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYON ERNEST ROSHONG DMD

Provider Business Mailing Address
First Line	:	111 W MADISON AVE
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-2908
Country	:	US
Telephone Number	:	201-387-1555
Fax Number	:	201-385-1268

Provider Business Practice Location Address
First Line	:	111 W MADISON AVE
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-2908
Country	:	US
Telephone Number	:	201-387-1555
Fax Number	:	201-385-1268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2005
Last Update Date	:	11/11/2012

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