Provider Demographics
NPI:1063634137
Name:SOUTH MOUNTAIN DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-378-2070
Mailing Address - Street 1:71 VALLEY ST
Mailing Address - Street 2:SUITE103
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079
Mailing Address - Country:US
Mailing Address - Phone:973-378-2070
Mailing Address - Fax:973-378-8334
Practice Address - Street 1:71 VALLEY ST
Practice Address - Street 2:SUITE103
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079
Practice Address - Country:US
Practice Address - Phone:973-378-2070
Practice Address - Fax:973-378-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ153831223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty