Healthcare Provider Details

I. General information

NPI: 1992981062
Provider Name (Legal Business Name): RIDGEWOOD DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 10/03/2013
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: 201-445-2040
Mailing address:
  • Phone: 201-445-4808
  • Fax: 201-445-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. WARREN BOARDMAN
Title or Position: DENTIST
Credential: DMD
Phone: 201-445-1060