Healthcare Provider Details

I. General information

NPI: 1174292734
Provider Name (Legal Business Name): NJ KIDS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2992 ABERDEEN RD
UNION NJ
07083
US

IV. Provider business mailing address

1205 COOLIDGE AVE
UNION NJ
07083-3720
US

V. Phone/Fax

Practice location:
  • Phone: 908-686-2080
  • Fax:
Mailing address:
  • Phone: 908-686-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALEJANDRIA RODRIGUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 908-686-2080