Healthcare Provider Details

I. General information

NPI: 1841439411
Provider Name (Legal Business Name): KEITH MURTAGH D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 07/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

269 WASHINGTON AVE
ISLAND PARK NY
11558-1305
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number053051
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number053051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: