Healthcare Provider Details

I. General information

NPI: 1093376907
Provider Name (Legal Business Name): GERARDO MUNGUIA RODRIGUEZ DMD, BD, MSD, CAGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2019
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

114 MADISON ST # 101
NEWARK NJ
07105-2108
US

V. Phone/Fax

Practice location:
  • Phone: 73-972-4242
  • Fax:
Mailing address:
  • Phone: 551-208-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number07400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: