Provider Demographics
NPI:1093909277
Name:MITNICK, NEAL IRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:IRA
Last Name:MITNICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6627
Mailing Address - Country:US
Mailing Address - Phone:718-494-1492
Mailing Address - Fax:718-701-2513
Practice Address - Street 1:2251 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6627
Practice Address - Country:US
Practice Address - Phone:718-494-1492
Practice Address - Fax:718-701-2513
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01178858Medicaid