Provider Demographics
NPI:1235479924
Name:WITROCK, ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:WITROCK
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 1:5225 NESCONSET HWY STE 40
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2060
Mailing Address - Country:US
Mailing Address - Phone:631-928-2830
Mailing Address - Fax:
Practice Address - Street 1:5225 NESCONSET HWY STE 40
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-928-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0405141223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics