Provider Demographics
NPI:1346454584
Name:RUTGERS HEALTH -UNIVERSITY DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:RUTGERS HEALTH -UNIVERSITY DENTAL ASSOCIATES
Other - Org Name:RUTGERS HEALTH GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICENTE
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-235-7631
Mailing Address - Street 1:90 BERGEN ST
Mailing Address - Street 2:SUITE 7700
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2425
Mailing Address - Country:US
Mailing Address - Phone:973-972-8668
Mailing Address - Fax:973-972-2441
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:SUITE 7700
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-2444
Practice Address - Fax:973-972-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223E0200X, 1223G0001X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0400X, 124Q00000X, 126800000X
NJ22DI019979001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ250009Medicaid
NJ250009Medicaid