Healthcare Provider Details

I. General information

NPI: 1316931561
Provider Name (Legal Business Name): MATTHEW GHADAMI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24902 JERICHO TPKE
FLORAL PARK NY
11001-4023
US

IV. Provider business mailing address

24902 JERICHO TPKE
FLORAL PARK NY
11001-4023
US

V. Phone/Fax

Practice location:
  • Phone: 516-354-1700
  • Fax: 516-354-4845
Mailing address:
  • Phone: 516-354-1700
  • Fax: 516-354-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number050254
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: