Provider Demographics
NPI:1144350430
Name:PROCTOR, EDMUND RICHARD JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:RICHARD
Last Name:PROCTOR
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:129 MONMOUTH ROAD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208
Mailing Address - Country:US
Mailing Address - Phone:908-527-6368
Mailing Address - Fax:
Practice Address - Street 1:12 MOEBUS PLACE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1023
Practice Address - Country:US
Practice Address - Phone:908-713-6677
Practice Address - Fax:908-713-6120
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD10139381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry