Healthcare Provider Details

I. General information

NPI: 1093922700
Provider Name (Legal Business Name): RIDGEWOOD DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CHESTNUT ST
RIDGEWOOD NJ
07450-2501
US

IV. Provider business mailing address

75 CHESTNUT ST
RIDGEWOOD NJ
07450-2501
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-4808
  • Fax: 201-445-9081
Mailing address:
  • Phone: 201-445-4808
  • Fax: 201-445-9081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01155300
License Number StateNJ

VIII. Authorized Official

Name: GLENN P GODART
Title or Position: OWNER
Credential: DMD
Phone: 201-445-4808