Provider Demographics
NPI:1114551587
Name:GRODKO, REBECCA ELLERIN (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELLERIN
Last Name:GRODKO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ELLERIN
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:596 S FOREST DR
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2011
Mailing Address - Country:US
Mailing Address - Phone:617-938-9189
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7494
Practice Address - Country:US
Practice Address - Phone:212-423-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY0619201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program