Provider Demographics
NPI:1831147032
Name:YOUDELMAN, STANLEY ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:ADAM
Last Name:YOUDELMAN
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 1:601 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-273-4888
Mailing Address - Fax:631-272-2398
Practice Address - Street 1:601 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-273-4888
Practice Address - Fax:631-272-2398
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0247191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT50021Medicare UPIN
NYD65691Medicare ID - Type Unspecified