Provider Demographics
NPI:1609379205
Name:VONDERHEIDE, MARIAM CLAIRE
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:CLAIRE
Last Name:VONDERHEIDE
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 1:147 MONTAGUE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3539
Mailing Address - Country:US
Mailing Address - Phone:585-610-9135
Mailing Address - Fax:
Practice Address - Street 1:44 COURT ST STE 808
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4414
Practice Address - Country:US
Practice Address - Phone:718-857-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-10
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0620591223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program