Provider Demographics
NPI:1346662012
Name:RIVER EDGE FAMILY DENTAL
Entity type:Organization
Organization Name:RIVER EDGE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIROSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-343-4044
Mailing Address - Street 1:130 KINDERKAMACK RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1939
Mailing Address - Country:US
Mailing Address - Phone:201-343-4044
Mailing Address - Fax:
Practice Address - Street 1:130 KINDERKAMACK RD
Practice Address - Street 2:SUITE 303
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-1939
Practice Address - Country:US
Practice Address - Phone:201-343-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02140900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty