Provider Demographics
NPI:1275961815
Name:BRIDGE ORAL-FACIAL SURGERY AND IMPLANT CENTER, LLC
Entity Type:Organization
Organization Name:BRIDGE ORAL-FACIAL SURGERY AND IMPLANT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOVINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-585-9800
Mailing Address - Street 1:2029 LEMOINE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5704
Mailing Address - Country:US
Mailing Address - Phone:201-585-9800
Mailing Address - Fax:201-585-9820
Practice Address - Street 1:2029 LEMOINE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5704
Practice Address - Country:US
Practice Address - Phone:201-585-9800
Practice Address - Fax:201-585-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0151091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty