Healthcare Provider Details

I. General information

NPI: 1467010561
Provider Name (Legal Business Name): ALEXIS MONA GHADAMI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 COMMACK RD
COMMACK NY
11725-5400
US

IV. Provider business mailing address

64 SADDLE LN
ROSLYN HEIGHTS NY
11577-2728
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-0531
  • Fax: 631-231-0561
Mailing address:
  • Phone: 516-661-7803
  • Fax: 516-354-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number061451
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: