Provider Demographics
NPI:1356550735
Name:TAMANAHA GRUNDY, ISABEL (DDS)
Entity type:Individual
Prefix:
First Name:ISABEL
Middle Name:
Last Name:TAMANAHA GRUNDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 VERMILYEA AVE
Mailing Address - Street 2:SUITE #27
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034
Mailing Address - Country:US
Mailing Address - Phone:212-567-1729
Mailing Address - Fax:212-567-0909
Practice Address - Street 1:145 VERMILYEA AVE
Practice Address - Street 2:SUITE #27
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034
Practice Address - Country:US
Practice Address - Phone:212-567-1729
Practice Address - Fax:212-567-0909
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0424091223G0001X
NJDI170241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01286108Medicaid