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General NPI Number Information
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NPI Number | 1144350430
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Entity Type | Individual
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Provider Name | EDMUND RICHARD PROCTOR JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 12 MOEBUS PLACE
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City | CLINTON
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State | NJ
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Zip | 08809-1023
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Country | US
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Telephone | 908-713-6677
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Fax | 908-713-6120
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Provider Business Mailing Address
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Address Line | 129 MONMOUTH ROAD
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City | ELIZABETH
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State | NJ
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Zip | 07208
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Country | US
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Telephone | 908-527-6368
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D1013938
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License Number State | NJ
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