Provider Demographics
NPI:1790041523
Name:BAILEY, EMIL (DMD)
Entity Type:Individual
Prefix:
First Name:EMIL
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5046
Mailing Address - Country:US
Mailing Address - Phone:347-801-8888
Mailing Address - Fax:347-801-8888
Practice Address - Street 1:555 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5046
Practice Address - Country:US
Practice Address - Phone:347-801-8888
Practice Address - Fax:347-801-8888
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0557551223X0400X
CA611661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055755OtherNY STATE DENTAL LICENSE
NY1902157910OtherGROUP NPI
NY455093797OtherTID
NY03437749Medicaid