Healthcare Provider Details

I. General information

NPI: 1164746087
Provider Name (Legal Business Name): JOHN IPPOLITO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 BAY RIDGE PKWY
BROOKLYN NY
11209-3329
US

IV. Provider business mailing address

615 BAY RIDGE PKWY
BROOKLYN NY
11209-3329
US

V. Phone/Fax

Practice location:
  • Phone: 718-745-4200
  • Fax: 718-745-4750
Mailing address:
  • Phone: 718-745-4200
  • Fax: 718-745-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number046015
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: