Healthcare Provider Details

I. General information

NPI: 1154313328
Provider Name (Legal Business Name): BRUCE ISRAEL LEIBOWITZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

66 NEWARK POMPTON TPKE
RIVERDALE NJ
07457-1420
US

IV. Provider business mailing address

66 NEWARK POMPTON TPKE
RIVERDALE NJ
07457-1420
US

V. Phone/Fax

Practice location:
  • Phone: 973-835-1195
  • Fax: 973-835-0234
Mailing address:
  • Phone: 973-835-1195
  • Fax: 973-835-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9685
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: