Healthcare Provider Details

I. General information

NPI: 1679944037
Provider Name (Legal Business Name): WILLER CONSTANT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 BEACH CHANNEL DR
ARVERNE NY
11692-1409
US

IV. Provider business mailing address

1200 E 53RD ST APT 5Y
BROOKLYN NY
11234-2344
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 718-945-2596
Mailing address:
  • Phone: 347-393-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number058259-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: