MEDICARE: ELIZABETH PHILIPONE D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22DI02289900	NJ
2	1223P0106X	Oral and Maxillofacial Pathology Dentistry	053889-1	NY

General Provider Information

NPI Number	:	1134312184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH PHILIPONE D.M.D.

Provider Business Mailing Address
First Line	:	630 W 168TH ST
Second Line	:	PH 1562 W
City	:	NEW YORK
State	:	NY
Zip	:	10032-3725
Country	:	US
Telephone Number	:	212-305-9235
Fax Number	:	212-305-5958

Provider Business Practice Location Address
First Line	:	630 W 168TH ST
Second Line	:	PH 1562 W
City	:	NEW YORK
State	:	NY
Zip	:	10032-3725
Country	:	US
Telephone Number	:	212-305-9235
Fax Number	:	212-305-5958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	09/25/2009

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