Provider Demographics
NPI:1306050869
Name:FORDHAM ROAD DENTAL PC
Entity type:Organization
Organization Name:FORDHAM ROAD DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-304-6110
Mailing Address - Street 1:327 E FORDHAM RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5002
Mailing Address - Country:US
Mailing Address - Phone:718-933-8400
Mailing Address - Fax:718-933-3731
Practice Address - Street 1:327 E FORDHAM RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5002
Practice Address - Country:US
Practice Address - Phone:718-933-8400
Practice Address - Fax:718-933-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty