Healthcare Provider Details

I. General information

NPI: 1528465465
Provider Name (Legal Business Name): ANNETTE KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 ROUTE 22
BREWSTER NY
10509-4051
US

IV. Provider business mailing address

455 OCEAN PKWY APT 3F
BROOKLYN NY
11218-5115
US

V. Phone/Fax

Practice location:
  • Phone: 845-279-4999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number058295
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: