Healthcare Provider Details

I. General information

NPI: 1396905014
Provider Name (Legal Business Name): MARLBORO FAMILY DENTAL AND FOOT CARE, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S MAIN ST
MARLBORO NJ
07746-1595
US

IV. Provider business mailing address

15 S MAIN ST
MARLBORO NJ
07746-1595
US

V. Phone/Fax

Practice location:
  • Phone: 732-414-1150
  • Fax: 732-414-1151
Mailing address:
  • Phone: 732-414-1150
  • Fax: 732-414-1151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22D101283400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00276700
License Number StateNJ

VIII. Authorized Official

Name: DR. CORINNE R KAUDERER
Title or Position: CEO
Credential: DPM
Phone: 732-414-1150