Basic Information
| Provider Information | |||||||||
| NPI: | 1174891352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPELAND | ||||||||
| FirstName: | GARRISON | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189927669 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1775 GRAND CONCOURSE FL 6 | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104538202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189927669 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 060920 | NY | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.