Provider Demographics
NPI:1841312261
Name:LON ROSEN
Entity type:Organization
Organization Name:LON ROSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LON
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-797-8100
Mailing Address - Street 1:15-01 BROADWAY STE 18
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6018
Mailing Address - Country:US
Mailing Address - Phone:201-797-8100
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY STE 18
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6018
Practice Address - Country:US
Practice Address - Phone:201-797-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014390001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty