Basic Information
Provider Information | |||||||||
NPI: | 1235220229 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NINA | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 COMMERCE LANE | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | NY | ||||||||
PostalCode: | 13617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153868791 | ||||||||
FaxNumber: | 3153861410 | ||||||||
Practice Location | |||||||||
Address1: | 4 COMMERCE LANE | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | NY | ||||||||
PostalCode: | 13617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153868791 | ||||||||
FaxNumber: | 3153861410 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 03/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0501271 | NY | N |   | Dental Providers | Dentist |   | 122300000X | 050127 | NY | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 9175712 | 01 | NY | DORAL | OTHER | 02348667 | 05 | NY |   | MEDICAID |