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Provider Information for 1215465901

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: 1215465901

Calendar   Last Updated:  2020-08-26
  Certification Date:  2020-08-26


Name Value
NPI 1215465901
Enumeration Date 2017-05-25
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 9931 64TH AVE APT B15
REGO PARK, NY 11374-2658
United States

Phone: 631-552-6324 | Fax:
View Map External Link
Primary Practice Address 511 CLINTON AVE
BROOKLYN, NY 11238-2246
United States

Phone: 718-416-6367 | Fax:
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 060092
No 1223G0001X - Dentist General Practice CT 11950