=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164874376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUTGERS UNIVERSITY DENTAL ASSOCIATES-NEW BRUNSWICK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2016
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 SOMERSET STREET SUITE A
-----------------------------------------------------
City | NEW BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08901-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-235-5050
-----------------------------------------------------
Fax | 732-220-0045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 SOMERSET STREET SUITE A
-----------------------------------------------------
City | NEW BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08901-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-235-5050
-----------------------------------------------------
Fax | 732-220-0045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR MGR BILLING & COLLECTIONS OFFICE
-----------------------------------------------------
Name | ROSEMARIE O VACCARO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-972-8664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02319600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------