Healthcare Provider Details

I. General information

NPI: 1407010028
Provider Name (Legal Business Name): MICHAEL ZIDILE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2008
Last Update Date: 09/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 MONTAGUE ST 9TH FLOOR
BROOKLYN NY
11201-3600
US

IV. Provider business mailing address

185 MONTAGUE ST 9TH FLOOR
BROOKLYN NY
11201-3600
US

V. Phone/Fax

Practice location:
  • Phone: 718-643-1953
  • Fax:
Mailing address:
  • Phone: 718-643-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number052187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: