Provider Demographics
NPI:1134324254
Name:KONDAK, EDWARD STEPHEN (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:STEPHEN
Last Name:KONDAK
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:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-0098
Mailing Address - Country:US
Mailing Address - Phone:631-477-1177
Mailing Address - Fax:631-477-1175
Practice Address - Street 1:135 3RD ST
Practice Address - Street 2:19-20 STERLINGTON COMMONS
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1640
Practice Address - Country:US
Practice Address - Phone:631-477-1177
Practice Address - Fax:631-477-1175
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0356321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00632866Medicaid
NY035632OtherLICENSE NUMBER