MEDICARE: JONATHAN ODINSKY

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	22D102956200	NJ
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223G0001X	General Practice Dentistry	061623-01	NY

General Provider Information

NPI Number	:	1326504564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ODINSKY

Provider Business Mailing Address
First Line	:	415 MADISON AVE
Second Line	:
City	:	WEST HEMPSTEAD
State	:	NY
Zip	:	11552-2352
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 BRIDGE PLZ N
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5051
Country	:	US
Telephone Number	:	201-429-0097
Fax Number	:

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

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	01/29/2024

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