Provider Demographics
NPI:1659748143
Name:DATZ, MALLORY R
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:R
Last Name:DATZ
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 1:286 MUNSELL RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5616
Mailing Address - Country:US
Mailing Address - Phone:631-312-3770
Mailing Address - Fax:
Practice Address - Street 1:286 MUNSELL RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-5616
Practice Address - Country:US
Practice Address - Phone:631-312-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY943033151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist