Provider Demographics
NPI:1912413170
Name:GENEVICIUTE, LORETA (DDS)
Entity Type:Individual
Prefix:
First Name:LORETA
Middle Name:
Last Name:GENEVICIUTE
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 1:415 E 37TH ST APT 36K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0139
Mailing Address - Country:US
Mailing Address - Phone:929-284-9277
Mailing Address - Fax:
Practice Address - Street 1:714 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2223
Practice Address - Country:US
Practice Address - Phone:631-473-0582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059543122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist