Healthcare Provider Details

I. General information

NPI: 1063671196
Provider Name (Legal Business Name): HOBOKEN ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 WASHINGTON ST
HOBOKEN NJ
07030-5169
US

IV. Provider business mailing address

726 WASHINGTON ST
HOBOKEN NJ
07030-5169
US

V. Phone/Fax

Practice location:
  • Phone: 201-792-7666
  • Fax:
Mailing address:
  • Phone: 201-792-7666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02309200
License Number StateNJ

VIII. Authorized Official

Name: DR. RUSSELL M SANDMAN
Title or Position: ORTHODONTIST
Credential: D.M.D., M.S.
Phone: 201-792-7666