Provider Demographics
NPI: | 1801813530 |
---|---|
Name: | ROSEBERRY FAMILY DENTAL |
Entity Type: | Organization |
Organization Name: | ROSEBERRY FAMILY DENTAL |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | PHILIP |
Authorized Official - Middle Name: | ANTHONY |
Authorized Official - Last Name: | BALDO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 908-859-5600 |
Mailing Address - Street 1: | 224 ROSEBERRY ST |
Mailing Address - Street 2: | SUITE #7 |
Mailing Address - City: | PHILLIPSBURG |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08865-1687 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 908-859-5600 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 224 ROSEBERRY ST |
Practice Address - Street 2: | SUITE #7 |
Practice Address - City: | PHILLIPSBURG |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08865-1687 |
Practice Address - Country: | US |
Practice Address - Phone: | 908-859-5600 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-17 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | DI20067 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |