Provider Demographics
NPI:1831302504
Name:RUTGERS SCHOOL OF DENTAL MEDICINE
Entity Type:Organization
Organization Name:RUTGERS SCHOOL OF DENTAL MEDICINE
Other - Org Name:UNIVERSITY DENTAL CENTER AT SOMERDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MDS
Authorized Official - Phone:856-566-6969
Mailing Address - Street 1:110 BERGEN ST
Mailing Address - Street 2:RSDM ROOM D-954
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 SOMERDALE SQ
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1345
Practice Address - Country:US
Practice Address - Phone:856-566-6969
Practice Address - Fax:856-566-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018341Medicaid