Healthcare Provider Details

I. General information

NPI: 1598733404
Provider Name (Legal Business Name): FRANK J PECORARO DDS PA RICHARD M KELNER DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 RARITAN RD SUITE 1
CLARK NJ
07066-1315
US

IV. Provider business mailing address

1119 RARITAN RD SUITE 1
CLARK NJ
07066-1315
US

V. Phone/Fax

Practice location:
  • Phone: 732-382-9090
  • Fax: 732-396-1527
Mailing address:
  • Phone: 732-382-9090
  • Fax: 732-396-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI00899901
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI02152901
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI00884501
License Number StateNJ

VIII. Authorized Official

Name: DR. RICHARD M KELNER
Title or Position: DOCTOR DMD
Credential: DMD
Phone: 732-382-9090