Healthcare Provider Details

I. General information

NPI: 1982930616
Provider Name (Legal Business Name): MICHAEL REALE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2009
Last Update Date: 10/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 DOGWOOD AVE SUTIE 109
FRANKLIN SQUARE NY
11010-3409
US

IV. Provider business mailing address

340 DOGWOOD AVE SUTIE 109
FRANKLIN SQUARE NY
11010-3409
US

V. Phone/Fax

Practice location:
  • Phone: 516-483-0800
  • Fax: 516-538-7358
Mailing address:
  • Phone: 516-483-0800
  • Fax: 516-538-7358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number045375
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: