Provider Demographics
NPI:1598977514
Name:KHODOSH, ROMAN (DDS)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:KHODOSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5918 BERGENLINE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-1392
Mailing Address - Country:US
Mailing Address - Phone:201-681-6555
Mailing Address - Fax:201-861-2999
Practice Address - Street 1:5918 BERGENLINE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1392
Practice Address - Country:US
Practice Address - Phone:201-681-6555
Practice Address - Fax:201-861-2999
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02185500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist