Healthcare Provider Details

I. General information

NPI: 1003860578
Provider Name (Legal Business Name): RANDOLPH CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 STATE ROUTE 10 SUITE 5
RANDOLPH NJ
07869-2132
US

IV. Provider business mailing address

447 STATE ROUTE 10 SUITE 5
RANDOLPH NJ
07869-2132
US

V. Phone/Fax

Practice location:
  • Phone: 973-328-1555
  • Fax: 973-328-3405
Mailing address:
  • Phone: 973-328-1555
  • Fax: 973-328-3405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI13367
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI18357
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI21013
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI22430
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI02286202
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI8562
License Number StateNJ

VIII. Authorized Official

Name: DR. EDWARD A ROSENBAUM
Title or Position: PARTNER
Credential: DMD
Phone: 973-328-1555