Basic Information
| Provider Information | |||||||||
| NPI: | 1922204734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDOR | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | MICHELLE LORMIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LORMIL | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 123 BEACH 61ST ST | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116921855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3478342857 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3711 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111011725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183615155 | ||||||||
| FaxNumber: | 7183615149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 054087 | NY | Y | Dental Providers | Dentist |
No ID Information.