Provider Demographics
NPI:1487215745
Name:RAISSI, BADR (DMD)
Entity Type:Individual
Prefix:
First Name:BADR
Middle Name:
Last Name:RAISSI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 WILLOW AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 CEDAR GROVE LN STE 102
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-4719
Practice Address - Country:US
Practice Address - Phone:732-357-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI02787200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program