Provider Demographics
NPI:1528064037
Name:TENNENBAUM, RICHARD NEIL (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:NEIL
Last Name:TENNENBAUM
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 1:474 HURFFVILLE-CROSS KEYS ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2319
Mailing Address - Country:US
Mailing Address - Phone:856-589-7900
Mailing Address - Fax:856-582-4686
Practice Address - Street 1:474 HURFFVILLE CROSSKEYS RD
Practice Address - Street 2:STE C
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2321
Practice Address - Country:US
Practice Address - Phone:856-589-7900
Practice Address - Fax:856-582-4686
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2901404Medicaid
153312Medicare PIN
NJ2901404Medicaid