Provider Demographics
NPI:1568723245
Name:SCHACK, KEVIN (DMD, MMSC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SCHACK
Suffix:
Gender:M
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2535
Mailing Address - Country:US
Mailing Address - Phone:914-481-1816
Mailing Address - Fax:
Practice Address - Street 1:3010 WESTCHESTER AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2535
Practice Address - Country:US
Practice Address - Phone:914-481-1816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051951-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics