Basic Information
Provider Information
NPI: 1588646855
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WETTAN
FirstName: STEVEN
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 911 HEWLETT DR
Address2:  
City: N. WOODMERE
State: NY
PostalCode: 115812726
CountryCode: US
TelephoneNumber: 5167917742
FaxNumber:  
Practice Location
Address1: 730 BROADWAY
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112064403
CountryCode: US
TelephoneNumber: 7189631919
FaxNumber: 7185994912
Other Information
ProviderEnumerationDate: 11/14/2005
LastUpdateDate: 10/22/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X026156NYY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
0051395105NY MEDICAID


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