Healthcare Provider Details

I. General information

NPI: 1730053091
Provider Name (Legal Business Name): REBECCA VAETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 DOGWOOD AVE STE 101
FRANKLIN SQUARE NY
11010-3400
US

IV. Provider business mailing address

14 BARCLAY ST
HUNTINGTON STATION NY
11746-2619
US

V. Phone/Fax

Practice location:
  • Phone: 516-565-2018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number064881
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: