Provider First Line Business Practice Location Address:
110 BERGEN ST # C781
Provider Second Line Business Practice Location Address:
UMDNJ DEPT OF PERIODONTICS
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07103-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-363-2050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2009