Healthcare Provider Details

I. General information

NPI: 1003059965
Provider Name (Legal Business Name): ROCKAWAY FAMILY DENTAL LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E MAIN ST STE A&B
ROCKAWAY NJ
07866-3614
US

IV. Provider business mailing address

200 E MAIN ST STE A&B
ROCKAWAY NJ
07866-3614
US

V. Phone/Fax

Practice location:
  • Phone: 973-784-4749
  • Fax: 973-784-4537
Mailing address:
  • Phone: 973-784-4749
  • Fax: 973-784-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02217100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02289200
License Number StateNJ

VIII. Authorized Official

Name: DR. WEIMIN JIN
Title or Position: OWNER
Credential:
Phone: 973-784-4749