Basic Information
| Provider Information | |||||||||
| NPI: | 1477577203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIFER | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 BEACH CHANNEL DR | ||||||||
| Address2: | |||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116921409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189457150 | ||||||||
| FaxNumber: | 7189452596 | ||||||||
| Practice Location | |||||||||
| Address1: | 6531 52ND AVE | ||||||||
| Address2: | P-1 | ||||||||
| City: | MASPETH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113781300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184575444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 026498 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02269703 | 05 | NY | MEDICAID |