Provider Demographics
NPI:1417004102
Name:TEFERA, ENDALE MULAT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ENDALE
Middle Name:MULAT
Last Name:TEFERA
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 1:444 VOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-3033
Mailing Address - Country:US
Mailing Address - Phone:973-275-0748
Mailing Address - Fax:718-778-2025
Practice Address - Street 1:944 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-3053
Practice Address - Country:US
Practice Address - Phone:718-778-3000
Practice Address - Fax:718-778-2025
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01171255Medicaid