Provider Demographics
NPI:1003827916
Name:MIZRAHI, RONALD DAVID (DDS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:DAVID
Last Name:MIZRAHI
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 1:372 AVENUE U
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4033
Mailing Address - Country:US
Mailing Address - Phone:718-998-5100
Mailing Address - Fax:718-382-0201
Practice Address - Street 1:372 AVENUE U
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4033
Practice Address - Country:US
Practice Address - Phone:718-998-5100
Practice Address - Fax:718-382-0201
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040858-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01349375Medicaid