Basic Information
Provider Information | |||||||||
NPI: | 1790987089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBINSON | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 165 MAIN ST | ||||||||
Address2: | OPEN DOOR FAMILY MEDICAL CENTER | ||||||||
City: | OSSINING | ||||||||
State: | NY | ||||||||
PostalCode: | 105624702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149411263 | ||||||||
FaxNumber: | 9147627224 | ||||||||
Practice Location | |||||||||
Address1: | 5 GRACE CHURCH ST | ||||||||
Address2: | OPEN DOOR FAMILY MEDICAL CENTERS, INC. | ||||||||
City: | PORT CHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 105734911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149377817 | ||||||||
FaxNumber: | 9149377732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 03/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 033391 | NY | Y |   | Dental Providers | Dentist |   | 122300000X | 11879NJ | NJ | N |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 00473029 | 05 | NY |   | MEDICAID |