Provider Demographics
NPI:1700533130
Name:HEGEDUS, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HEGEDUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 32ND ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:549 STEWART AVE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-2706
Practice Address - Country:US
Practice Address - Phone:516-490-7707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-06
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0634481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program