Provider Demographics
NPI:1376089292
Name:DENHARTOG, MICHELLE (BA)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:DENHARTOG
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WOODS DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3600
Mailing Address - Country:US
Mailing Address - Phone:631-807-6566
Mailing Address - Fax:
Practice Address - Street 1:12 WOODS DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3600
Practice Address - Country:US
Practice Address - Phone:631-807-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1097304171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist