Provider Demographics
NPI:1417039421
Name:FISCHMAN, BRADLEY M
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:M
Last Name:FISCHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 E SHORE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2433
Mailing Address - Country:US
Mailing Address - Phone:516-482-5924
Mailing Address - Fax:888-311-9754
Practice Address - Street 1:233 E SHORE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2433
Practice Address - Country:US
Practice Address - Phone:516-482-5924
Practice Address - Fax:888-311-9754
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0287871223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT49911Medicare UPIN
NYD6A891Medicare UPIN