Provider Demographics
NPI:1801962139
Name:JUSTUS-TAUER, KIMBERLY KERRY (DDS)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KERRY
Last Name:JUSTUS-TAUER
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 1:12 MEEKS LN
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3706
Mailing Address - Country:US
Mailing Address - Phone:631-224-1623
Mailing Address - Fax:631-581-0635
Practice Address - Street 1:61 NASSAU AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3607
Practice Address - Country:US
Practice Address - Phone:631-277-5099
Practice Address - Fax:631-581-0635
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0481831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02120327Medicaid