Provider Demographics
NPI:1053745117
Name:RANDOLPH ORAL PATHOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:RANDOLPH ORAL PATHOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-945-9309
Mailing Address - Street 1:447 ROUTE 10
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2132
Mailing Address - Country:US
Mailing Address - Phone:973-328-0464
Mailing Address - Fax:
Practice Address - Street 1:447 ROUTE 10
Practice Address - Street 2:SUITE 5
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2132
Practice Address - Country:US
Practice Address - Phone:973-328-0464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025460001223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty