Provider Demographics
NPI:1205219714
Name:DONOVAN, ADAM (DDS)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DONOVAN
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 1:8645 251ST ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2407
Mailing Address - Country:US
Mailing Address - Phone:516-417-0414
Mailing Address - Fax:
Practice Address - Street 1:8645 251ST ST
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2407
Practice Address - Country:US
Practice Address - Phone:516-417-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058828-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice