Healthcare Provider Details

I. General information

NPI: 1124016472
Provider Name (Legal Business Name): RONALD FEDERMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 N VAN BRUNT ST SUITE 29
ENGLEWOOD NJ
07631-2740
US

IV. Provider business mailing address

40 N VAN BRUNT ST SUITE 29
ENGLEWOOD NJ
07631-2740
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-0888
  • Fax: 201-871-4622
Mailing address:
  • Phone: 201-894-0888
  • Fax: 201-871-4622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberNJ10543
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: