Provider Demographics
NPI:1013087790
Name:PRUDEN, PETER H (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:H
Last Name:PRUDEN
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 1:177 MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6917
Mailing Address - Country:US
Mailing Address - Phone:631-421-2471
Mailing Address - Fax:631-547-6809
Practice Address - Street 1:177 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6917
Practice Address - Country:US
Practice Address - Phone:631-421-2471
Practice Address - Fax:631-547-6809
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0346611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT49247Medicare UPIN
NYD0E231Medicare ID - Type Unspecified