1275961815 NPI number — BRIDGE ORAL-FACIAL SURGERY AND IMPLANT CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275961815 NPI number — BRIDGE ORAL-FACIAL SURGERY AND IMPLANT CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE ORAL-FACIAL SURGERY AND IMPLANT CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275961815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2029 LEMOINE AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
FORT LEE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07024-5704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-585-9800
Provider Business Mailing Address Fax Number:
201-585-9820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2029 LEMOINE AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FORT LEE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07024-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-585-9800
Provider Business Practice Location Address Fax Number:
201-585-9820
Provider Enumeration Date:
10/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOVINO
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
201-585-9800

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  015109 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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