Provider Demographics
NPI:1396914396
Name:ROSELLE COMMONS DENTAL CENTER, PC
Entity type:Organization
Organization Name:ROSELLE COMMONS DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-259-0505
Mailing Address - Street 1:711 E 1ST AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-1669
Mailing Address - Country:US
Mailing Address - Phone:908-259-0505
Mailing Address - Fax:908-259-9885
Practice Address - Street 1:711 E 1ST AVE STE 5
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-1669
Practice Address - Country:US
Practice Address - Phone:908-259-0505
Practice Address - Fax:908-259-9885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02001800261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7353103Medicaid