Basic Information
| Provider Information | |||||||||
| NPI: | 1306110853 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINTHROP DENTAL PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 700 HICKSVILLE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165765810 | ||||||||
| FaxNumber: | 5165765801 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632752 | ||||||||
| FaxNumber: | 5166639373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2012 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBBINS | ||||||||
| AuthorizedOfficialFirstName: | MIRIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CO-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5166631152 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | A100082960 | 01 | NY | MEDICARE GROUP NUMBER | OTHER |