Provider Demographics
NPI:1619418316
Name:RENDA, JOSEPH MATTHEW
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:RENDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2822
Mailing Address - Country:US
Mailing Address - Phone:516-672-5752
Mailing Address - Fax:
Practice Address - Street 1:60 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2822
Practice Address - Country:US
Practice Address - Phone:516-672-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY059963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program