Provider Demographics
NPI:1194814434
Name:FADER, GREGG R (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:R
Last Name:FADER
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:ONE JORDAN LANE
Mailing Address - Street 2:
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502
Mailing Address - Country:US
Mailing Address - Phone:914-693-4442
Mailing Address - Fax:
Practice Address - Street 1:504 GRAND STREET
Practice Address - Street 2:#M3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:212-475-0051
Practice Address - Fax:212-475-3279
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0409721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics