Provider Demographics
NPI:1942419833
Name:ETRI, DEAN J (DC)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:J
Last Name:ETRI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BRUNO LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-2227
Mailing Address - Country:US
Mailing Address - Phone:347-751-5199
Mailing Address - Fax:718-338-7117
Practice Address - Street 1:2116 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1507
Practice Address - Country:US
Practice Address - Phone:347-751-5199
Practice Address - Fax:718-338-7117
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005951111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU18099Medicare UPIN
NYX37621Medicare ID - Type Unspecified