Provider Demographics
NPI:1750443206
Name:GERALD S. CONVISSAR DDS PA
Entity Type:Organization
Organization Name:GERALD S. CONVISSAR DDS PA
Other - Org Name:RANCOCAS WOODS FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:CONVISSAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-778-8655
Mailing Address - Street 1:1373 HEARTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2741
Mailing Address - Country:US
Mailing Address - Phone:856-778-8655
Mailing Address - Fax:856-231-7480
Practice Address - Street 1:2 RANCOCAS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2057
Practice Address - Country:US
Practice Address - Phone:856-778-8655
Practice Address - Fax:856-231-7480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI011968001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty