Provider Demographics
NPI:1699346437
Name:PRECIDENT OF NEW JERSEY, LLC
Entity type:Organization
Organization Name:PRECIDENT OF NEW JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOLDING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:479-957-4611
Mailing Address - Street 1:PO BOX 2714
Mailing Address - Street 2:DEPT 2243
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-2714
Mailing Address - Country:US
Mailing Address - Phone:973-256-0103
Mailing Address - Fax:973-256-8066
Practice Address - Street 1:1135 BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3346
Practice Address - Country:US
Practice Address - Phone:973-256-0103
Practice Address - Fax:973-256-8066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI02335600OtherNJ STATE LICENSE
NJ22DI02335601OtherNJ STATE LICENSE BRANCH OFFICE