Provider Demographics
NPI:1427096924
Name:BOARDMAN, WARREN ELLIOT (DMD)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:ELLIOT
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2501
Mailing Address - Country:US
Mailing Address - Phone:201-445-4808
Mailing Address - Fax:201-445-2040
Practice Address - Street 1:75 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2501
Practice Address - Country:US
Practice Address - Phone:201-445-4808
Practice Address - Fax:201-445-2040
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017532001223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6698890001Medicare NSC