Provider Demographics
NPI:1003860578
Name:RANDOLPH CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, PA
Entity Type:Organization
Organization Name:RANDOLPH CENTER FOR ORAL AND MAXILLOFACIAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-328-1555
Mailing Address - Street 1:447 STATE ROUTE 10
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2132
Mailing Address - Country:US
Mailing Address - Phone:973-328-1555
Mailing Address - Fax:973-328-3405
Practice Address - Street 1:447 STATE ROUTE 10
Practice Address - Street 2:SUITE 5
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2132
Practice Address - Country:US
Practice Address - Phone:973-328-1555
Practice Address - Fax:973-328-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI133671223S0112X
NJDI183571223S0112X
NJDI210131223S0112X
NJDI224301223S0112X
NJDI022862021223S0112X
NJDI85621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01987324Medicaid
NJ1478109Medicaid
NY01984078Medicaid
NJ7796609Medicaid
NJ018242MKVMedicare ID - Type UnspecifiedGROUP NUMBER
NYU67745Medicare UPIN
NJU24714Medicare UPIN
NJT99342Medicare UPIN
NY01987324Medicaid
NJ7796609Medicaid