Healthcare Provider Details

I. General information

NPI: 1487883294
Provider Name (Legal Business Name): SUSAN GAIL TIERNEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 NASSAU BLVD
GARDEN CITY NY
11530
US

IV. Provider business mailing address

154 NASSAU BLVD
GARDEN CITY NY
11530
US

V. Phone/Fax

Practice location:
  • Phone: 516-747-4541
  • Fax: 516-747-4663
Mailing address:
  • Phone: 516-747-4541
  • Fax: 516-747-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number037205
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: