Healthcare Provider Details

I. General information

NPI: 1962492181
Provider Name (Legal Business Name): GRACE ENCARNACION CHIN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 05/31/2020
Certification Date: 05/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST MONTEFIORE MEDICAL CENTER- PEDIATRIC DENTISTRY
BRONX NY
10467-2401
US

IV. Provider business mailing address

259 KINDERKAMACK RD
WESTWOOD NJ
07675-2204
US

V. Phone/Fax

Practice location:
  • Phone: 347-577-4950
  • Fax: 347-577-4926
Mailing address:
  • Phone: 718-619-1529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8940
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02267701
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02267700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS038115
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number049650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: