Provider Demographics
NPI:1255826939
Name:RIVERSIDE ORAL SURGERY - LIVINGSTON
Entity Type:Organization
Organization Name:RIVERSIDE ORAL SURGERY - LIVINGSTON
Other - Org Name:RIVERSIDE ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-487-6565
Mailing Address - Street 1:130 KINDERKAMACK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1931
Mailing Address - Country:US
Mailing Address - Phone:201-487-6565
Mailing Address - Fax:
Practice Address - Street 1:340 E NORTHFIELD RD STE 1C
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4892
Practice Address - Country:US
Practice Address - Phone:973-992-4750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025848051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI02584805OtherSTATE DENTAL LICENSE