Healthcare Provider Details

I. General information

NPI: 1194895466
Provider Name (Legal Business Name): RUDOLPH R LEIDL DMD FACD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MOUNTAIN VIEW AVE
LONG VALLEY NJ
07853
US

IV. Provider business mailing address

2 MOUNTAIN VIEW AVE
LONG VALLEY NJ
07853
US

V. Phone/Fax

Practice location:
  • Phone: 908-876-3458
  • Fax: 908-876-9121
Mailing address:
  • Phone: 908-876-3458
  • Fax: 908-876-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI01106300
License Number StateNJ

VIII. Authorized Official

Name: DR. RUDOLPH R LEIDL
Title or Position: OWNER PRESIDENT
Credential: DMD
Phone: 908-876-3458