Provider Demographics
NPI:1326372962
Name:MANDRACCHIA, MARTINE ROLANDE
Entity Type:Individual
Prefix:DR
First Name:MARTINE
Middle Name:ROLANDE
Last Name:MANDRACCHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 STEWART AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4823
Mailing Address - Country:US
Mailing Address - Phone:516-742-6845
Mailing Address - Fax:516-742-2706
Practice Address - Street 1:901 STEWART AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4823
Practice Address - Country:US
Practice Address - Phone:516-742-6845
Practice Address - Fax:516-742-2706
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038669-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice