Provider Demographics
NPI:1497822597
Name:ROSIVACK, RICHARD G (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:ROSIVACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:R
Other - Middle Name:GLENN
Other - Last Name:ROSIVACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:381 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-9430
Mailing Address - Country:US
Mailing Address - Phone:908-686-2082
Mailing Address - Fax:908-686-2149
Practice Address - Street 1:381 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9430
Practice Address - Country:US
Practice Address - Phone:908-686-2082
Practice Address - Fax:908-686-2149
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ137631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1345001Medicaid