Provider Demographics
NPI:1649649856
Name:BIVONA, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:BIVONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 ALLWOOD RD APT 3
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-2136
Mailing Address - Country:US
Mailing Address - Phone:909-938-3800
Mailing Address - Fax:862-899-7609
Practice Address - Street 1:345 EAST 24TH ST
Practice Address - Street 2:NYUCD
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010
Practice Address - Country:US
Practice Address - Phone:212-998-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027261-1122300000X
CA51167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist