Provider Demographics
NPI:1649324757
Name:GUTMAN, RONALD J (DMD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:GUTMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 PARK AVE
Mailing Address - Street 2:APARTMENT 5A-1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1211
Mailing Address - Country:US
Mailing Address - Phone:212-423-0730
Mailing Address - Fax:
Practice Address - Street 1:865 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3105
Practice Address - Country:US
Practice Address - Phone:718-941-7400
Practice Address - Fax:718-856-6218
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0308451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00291103Medicaid