Provider Demographics
NPI:1619368883
Name:MANSDORF, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:MANSDORF
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 1:858 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 W 57TH ST STE 915
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2401
Practice Address - Country:US
Practice Address - Phone:212-245-1066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY058595-11223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program