Healthcare Provider Details

I. General information

NPI: 1699346437
Provider Name (Legal Business Name): PRECIDENT OF NEW JERSEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 BROAD ST STE 100
CLIFTON NJ
07013-3346
US

IV. Provider business mailing address

PO BOX 2714 DEPT 2243
CONWAY AR
72033-2714
US

V. Phone/Fax

Practice location:
  • Phone: 973-256-0103
  • Fax: 973-256-8066
Mailing address:
  • Phone: 973-256-0103
  • Fax: 973-256-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTTY L BOLDING
Title or Position: OWNER
Credential: DDS, MS
Phone: 479-957-4611