Provider Demographics
NPI:1649379355
Name:VICTOR, RICHARD JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
Last Name:VICTOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-7207
Mailing Address - Country:US
Mailing Address - Phone:732-695-2202
Mailing Address - Fax:732-695-2205
Practice Address - Street 1:2105 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-7207
Practice Address - Country:US
Practice Address - Phone:732-695-2202
Practice Address - Fax:732-695-2205
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI015453001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI01545300OtherSTATE LICENSE/CERTIFICATE