=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063634137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH MOUNTAIN DENTAL SPECIALTY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 VALLEY ST SUITE103
-----------------------------------------------------
City | SOUTH ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-378-2070
-----------------------------------------------------
Fax | 973-378-8334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 VALLEY ST SUITE103
-----------------------------------------------------
City | SOUTH ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-378-2070
-----------------------------------------------------
Fax | 973-378-8334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. RALPH C GRAY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 973-378-2070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 15383
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------