Provider Demographics
NPI:1851594741
Name:AIVES, JONATHAN STEPHEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:STEPHEN
Last Name:AIVES
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 1:2 1/2 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12167
Mailing Address - Country:US
Mailing Address - Phone:607-652-4333
Mailing Address - Fax:607-652-4333
Practice Address - Street 1:356 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013
Practice Address - Country:US
Practice Address - Phone:718-843-0572
Practice Address - Fax:718-843-0572
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0357381223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00854311Medicaid