Provider Demographics
NPI:1720408990
Name:FELLINE, ADAM
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:FELLINE
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 1:1987 CYNTHIA LN
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5111
Mailing Address - Country:US
Mailing Address - Phone:646-270-5152
Mailing Address - Fax:
Practice Address - Street 1:1987 CYNTHIA LN
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-5111
Practice Address - Country:US
Practice Address - Phone:646-270-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3902000000X122300000X
NY0581601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist