Provider Demographics
NPI:1508120304
Name:GENTRY, MAXINE
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:
Last Name:GENTRY
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 1:50 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1445
Mailing Address - Country:US
Mailing Address - Phone:914-414-3627
Mailing Address - Fax:
Practice Address - Street 1:20 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-5247
Practice Address - Country:US
Practice Address - Phone:914-576-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist