Provider Demographics
NPI:1942421409
Name:MADANI, MEYSAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEYSAM
Middle Name:
Last Name:MADANI
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 1:5812 QUEENS BLVD APT 8J
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-7778
Mailing Address - Country:US
Mailing Address - Phone:646-319-2717
Mailing Address - Fax:
Practice Address - Street 1:247-09A UNION TURNPIKE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426
Practice Address - Country:US
Practice Address - Phone:718-506-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0524731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02864597Medicaid