MEDICARE: INNOVATIVE DENTISTRY, P.C.

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	22DI02201400	NJ

General Provider Information

NPI Number	:	1528254851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE DENTISTRY, P.C.

Provider Business Mailing Address
First Line	:	546 SAINT GEORGES AVE
Second Line	:
City	:	RAHWAY
State	:	NJ
Zip	:	07065-2542
Country	:	US
Telephone Number	:	732-882-1700
Fax Number	:	732-882-1799

Provider Business Practice Location Address
First Line	:	546 SAINT GEORGES AVE
Second Line	:
City	:	RAHWAY
State	:	NJ
Zip	:	07065-2542
Country	:	US
Telephone Number	:	732-882-1700
Fax Number	:	732-882-1799

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RAJDEEP SINGH RANDHAWA
Credential	:	D.D.S.
Telephone Number	:	732-882-1700

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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