Provider Demographics
NPI:1144598590
Name:RONALD DEUTSEN DDS PC
Entity Type:Organization
Organization Name:RONALD DEUTSEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEUTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-253-2300
Mailing Address - Street 1:2016 AVE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210
Mailing Address - Country:US
Mailing Address - Phone:718-253-2300
Mailing Address - Fax:718-252-7910
Practice Address - Street 1:1122 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-253-2300
Practice Address - Fax:718-252-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049859122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02241858Medicaid