Healthcare Provider Details

I. General information

NPI: 1356433122
Provider Name (Legal Business Name): SANG RO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DEWOLF RD STE 207
OLD TAPPAN NJ
07675-7015
US

IV. Provider business mailing address

1 DEWOLF RD STE 207
OLD TAPPAN NJ
07675-7015
US

V. Phone/Fax

Practice location:
  • Phone: 201-750-7857
  • Fax: 201-750-9070
Mailing address:
  • Phone: 201-750-7857
  • Fax: 201-750-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22DI02109800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: