Provider Demographics
NPI:1679774798
Name:LIECHTUNG, MORDECIA MARC (DMD)
Entity Type:Individual
Prefix:DR
First Name:MORDECIA
Middle Name:MARC
Last Name:LIECHTUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:
Other - Last Name:LIECHTUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:111 E 85TH ST
Mailing Address - Street 2:APARTMENT #8F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0958
Mailing Address - Country:US
Mailing Address - Phone:917-685-8560
Mailing Address - Fax:
Practice Address - Street 1:1995 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5882
Practice Address - Country:US
Practice Address - Phone:212-247-2330
Practice Address - Fax:212-501-9471
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040754-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY134148576OtherMETM LIFE DENTAL