Provider Demographics
NPI:1447657879
Name:CENTER FOR ORAL SURGERY & DENTAL IMPLANTS OF ROSELLE LLC
Entity type:Organization
Organization Name:CENTER FOR ORAL SURGERY & DENTAL IMPLANTS OF ROSELLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-241-2114
Mailing Address - Street 1:2305 WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-2939
Mailing Address - Country:US
Mailing Address - Phone:908-241-2114
Mailing Address - Fax:
Practice Address - Street 1:2305 WOOD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-2939
Practice Address - Country:US
Practice Address - Phone:908-241-2114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017127001223S0112X
NJ22DI024058161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty