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Provider Information for 1093916686

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1093916686

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1093916686
Enumeration Date 2007-05-30
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1215 AVENUE N APT.2G
BROOKLYN, NY 11230-5960
United States

Phone: 718-336-9844 | Fax:
View Map External Link
Primary Practice Address 9626 AVENUE N
BROOKLYN, NY 11236-5306
United States

Phone: 718-251-4444 | Fax: 718-251-3614
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice NY 046523