Provider Demographics
NPI:1740589548
Name:CHEATHAM, MARY E
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:CHEATHAM
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 1:85 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2722
Mailing Address - Country:US
Mailing Address - Phone:516-996-8162
Mailing Address - Fax:
Practice Address - Street 1:2110 NORTHERN BLVD STE 204
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3500
Practice Address - Country:US
Practice Address - Phone:516-365-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0563321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program