Healthcare Provider Details

I. General information

NPI: 1962788976
Provider Name (Legal Business Name): JUDY DIDONATO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 SIXTH AVE
BROOKLYN NY
11209
US

IV. Provider business mailing address

7317 SIXTH AVE
BROOKLYN NY
11209
US

V. Phone/Fax

Practice location:
  • Phone: 718-921-5194
  • Fax: 718-921-4780
Mailing address:
  • Phone: 718-921-5194
  • Fax: 718-921-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number040362
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: