Provider Demographics
NPI:1144203613
Name:LEVINE, BRAD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:LEVINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2946
Mailing Address - Country:US
Mailing Address - Phone:516-767-9300
Mailing Address - Fax:
Practice Address - Street 1:14 MAPLE ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2946
Practice Address - Country:US
Practice Address - Phone:516-767-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0405211223E0200X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02254731Medicaid
NY02254731Medicaid