Basic Information
| Provider Information | |||||||||
| NPI: | 1235220229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NINA | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | DDS | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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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 |