Provider Demographics
NPI:1326105594
Name:MOMTAHENI, DAVID M (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:MOMTAHENI
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 1:630 5TH AVE.
Mailing Address - Street 2:1868
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10111-1862
Mailing Address - Country:US
Mailing Address - Phone:212-969-9133
Mailing Address - Fax:212-969-9108
Practice Address - Street 1:630 5TH AVE
Practice Address - Street 2:1868
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10111-0100
Practice Address - Country:US
Practice Address - Phone:212-969-9133
Practice Address - Fax:212-969-9108
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDOE182Medicare PIN