Provider Demographics
NPI:1558744698
Name:LIM, DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2631
Mailing Address - Country:US
Mailing Address - Phone:610-739-9503
Mailing Address - Fax:
Practice Address - Street 1:189 WHEATLEY RD
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-2641
Practice Address - Country:US
Practice Address - Phone:631-361-6605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18569651223G0001X
390200000X
NY0594231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program