Healthcare Provider Details

I. General information

NPI: 1376004366
Provider Name (Legal Business Name): INDIANA CASTRO AUDE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

IV. Provider business mailing address

11535 MAIN RD
MATTITUCK NY
11952-1687
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-5100
  • Fax:
Mailing address:
  • Phone: 631-298-5021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number061435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: