Provider Demographics
NPI:1760524078
Name:NEW DENTAL IMAGE ASSO.CORP
Entity Type:Organization
Organization Name:NEW DENTAL IMAGE ASSO.CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:P
Authorized Official - Last Name:WERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-295-1706
Mailing Address - Street 1:9238 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5312
Mailing Address - Country:US
Mailing Address - Phone:201-295-1706
Mailing Address - Fax:201-295-9507
Practice Address - Street 1:9238 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5312
Practice Address - Country:US
Practice Address - Phone:201-295-1706
Practice Address - Fax:201-295-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0086185Medicaid