Provider Demographics
NPI:1407069107
Name:RUTGERS SCHOOL OF DENTAL MEDICINE
Entity Type:Organization
Organization Name:RUTGERS SCHOOL OF DENTAL MEDICINE
Other - Org Name:UNIVERSITY JOHN H. CRONIN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CODE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-645-5814
Mailing Address - Street 1:110 BERGEN ST
Mailing Address - Street 2:RSDM ROOM D-954
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 DOLPHIN AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-2015
Practice Address - Country:US
Practice Address - Phone:609-645-5814
Practice Address - Fax:609-645-5872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018384Medicaid