Basic Information
| Provider Information | |||||||||
| NPI: | 1992765689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTROMIHALIS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100073001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127327400 | ||||||||
| FaxNumber: | 2127320267 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100073001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127327400 | ||||||||
| FaxNumber: | 2127320267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | 050032 | NY | Y | Dental Providers | Dentist | Endodontics |
ID Information
| ID | Type | State | Issuer | Description | 02672755 | 05 | NY | MEDICAID |