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General NPI Number Information
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NPI Number | 1487215745
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Entity Type | Individual
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Provider Name | BADR RAISSI D.M.D
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Gender | Male
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Dates
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Enumeration Date | 06/26/2019
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Last Update Date | 01/11/2021
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Provider Practice Location Address
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Address Line | 107 CEDAR GROVE LN STE 102
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City | SOMERSET
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State | NJ
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Zip | 08873-4719
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Country | US
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Telephone | 732-357-3770
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Fax |
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Provider Business Mailing Address
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Address Line | 832 WILLOW AVE APT 3D
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City | HOBOKEN
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State | NJ
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Zip | 07030-2906
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Country | US
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Telephone |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02787200
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License Number State | NJ
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