Healthcare Provider Details

I. General information

NPI: 1033538772
Provider Name (Legal Business Name): MARIA NEMELIVSKY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 BRIGGS HIGHWAY
ELLENVILLE NY
12428-5501
US

IV. Provider business mailing address

89-56 162ND STREET 3RD FLOOR
JAMACIA NY
11432-5072
US

V. Phone/Fax

Practice location:
  • Phone: 845-647-2000
  • Fax: 845-647-2302
Mailing address:
  • Phone: 718-657-1100
  • Fax: 718-657-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number057945
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: