Healthcare Provider Details

I. General information

NPI: 1164974846
Provider Name (Legal Business Name): BROWNSTONE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MONTAGUE ST
BROOKLYN NY
11201-3482
US

IV. Provider business mailing address

120 MONTAGUE ST
BROOKLYN NY
11201-3482
US

V. Phone/Fax

Practice location:
  • Phone: 718-855-2855
  • Fax: 866-221-4121
Mailing address:
  • Phone: 718-855-2855
  • Fax: 866-221-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number052448
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number054412
License Number StateNY

VIII. Authorized Official

Name: DR. MARTIN CORMAC MACDERMONTT
Title or Position: OWNER
Credential:
Phone: 718-855-2855