Provider Demographics
NPI:1053509687
Name:STATEN ISLAND PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:STATEN ISLAND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-761-7316
Mailing Address - Street 1:195 BRIDGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6006
Mailing Address - Country:US
Mailing Address - Phone:718-761-7316
Mailing Address - Fax:718-761-0558
Practice Address - Street 1:195 BRIDGETOWN ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6006
Practice Address - Country:US
Practice Address - Phone:718-761-7316
Practice Address - Fax:718-761-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04252911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty