Provider Demographics
NPI:1992981062
Name:RIDGEWOOD DENTAL GROUP LLC
Entity type:Organization
Organization Name:RIDGEWOOD DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-445-1060
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6698890001Medicare NSC