Healthcare Provider Details

I. General information

NPI: 1821127580
Provider Name (Legal Business Name): MARIYA ROZENBLUM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 CEDAR LN STE L7
TEANECK NJ
07666-4303
US

IV. Provider business mailing address

2444 2ND ST # A
FORT LEE NJ
07024-4042
US

V. Phone/Fax

Practice location:
  • Phone: 201-836-9191
  • Fax:
Mailing address:
  • Phone: 201-294-6324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22DI02237100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number050892
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: