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Provider Information for 1588787717

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: 1588787717

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


Name Value
NPI 1588787717
Enumeration Date 2007-04-10
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 301 E 79TH ST APT 29R
NEW YORK, NY 10021-0951
United States

Phone: 212-794-1722 | Fax: 212-826-5060
View Map External Link
Primary Practice Address 310 E SHORE RD SUITE 101
GREAT NECK, NY 11023-2432
United States

Phone: 516-487-3787 | 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 1223X0400X - Dentist Orthodontics and Dentofacial Orthopedics NY 048497-1