=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407069107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUTGERS SCHOOL OF DENTAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 05/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 DOLPHIN AVE
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-645-5814
-----------------------------------------------------
Fax | 609-645-5872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 BERGEN ST RSDM ROOM D-954
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103-2495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CODE DIRECTOR
-----------------------------------------------------
Name | DR. DAVID BOLGER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 609-645-5814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------