Provider Demographics
NPI:1083691638
Name:MORI, JUDITH (DDS)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:MORI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W
Mailing Address - Street 2:SUITE 10
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1323
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:2 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1402
Practice Address - Country:US
Practice Address - Phone:845-294-8806
Practice Address - Fax:845-294-8650
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0396111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02640673Medicaid