Provider Demographics
NPI:1992803324
Name:WIDMAYER, DEREK (DMD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:WIDMAYER
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 1:769 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 154
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1198
Mailing Address - Country:US
Mailing Address - Phone:973-736-0111
Mailing Address - Fax:973-325-3442
Practice Address - Street 1:769 NORTHFIELD AVE
Practice Address - Street 2:SUITE 154
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1198
Practice Address - Country:US
Practice Address - Phone:973-736-0111
Practice Address - Fax:973-325-3442
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ212601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice