Provider Demographics
NPI:1922204734
Name:MEDOR, MARIE MICHELLE LORMIL (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MICHELLE LORMIL
Last Name:MEDOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:MICHELLE
Other - Last Name:LORMIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:123 BEACH 61ST ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1855
Mailing Address - Country:US
Mailing Address - Phone:347-834-2857
Mailing Address - Fax:
Practice Address - Street 1:3711 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-1725
Practice Address - Country:US
Practice Address - Phone:718-361-5155
Practice Address - Fax:718-361-5149
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist