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General NPI Number Information
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NPI Number | 1255826939
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Entity Type | Organization
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Legal Business Name | RIVERSIDE ORAL SURGERY - LIVINGSTON
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Dates
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Enumeration Date | 06/26/2018
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Last Update Date | 09/26/2022
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Provider Practice Location Address
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Address Line | 340 E NORTHFIELD RD STE 1C
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City | LIVINGSTON
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State | NJ
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Zip | 07039-4892
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Country | US
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Telephone | 973-992-4750
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Fax |
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Provider Business Mailing Address
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Address Line | 130 KINDERKAMACK RD STE 204
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City | RIVER EDGE
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State | NJ
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Zip | 07661-1931
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Country | US
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Telephone | 201-487-6565
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MISS LISA D BROWN
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Credential |
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Telephone | 201-487-6565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 22DI02584805
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License Number State | NJ
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