Provider Demographics
NPI:1659944601
Name:RIDGEWOOD ORAL SURGERY CENTER LLC
Entity Type:Organization
Organization Name:RIDGEWOOD ORAL SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP INSURANCE PLAN MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-424-2990
Mailing Address - Street 1:385 S MAPLE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 S MAPLE AVE STE 207
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1545
Practice Address - Country:US
Practice Address - Phone:201-444-5355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty