Provider Demographics
NPI:1659462026
Name:BRODY, STEWART CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:CHARLES
Last Name:BRODY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MAPLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2000
Mailing Address - Country:US
Mailing Address - Phone:516-482-2215
Mailing Address - Fax:516-482-5410
Practice Address - Street 1:17 MAPLE DRIVE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2000
Practice Address - Country:US
Practice Address - Phone:516-482-2215
Practice Address - Fax:516-482-5410
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401361223G0001X
NY040136-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice