Healthcare Provider Details

I. General information

NPI: 1871059113
Provider Name (Legal Business Name): KELLY MASTROVITO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 STEWART AVE STE LL60
GARDEN CITY NY
11530-4786
US

IV. Provider business mailing address

305 HENRY ST APT 3R
BROOKLYN NY
11201-5567
US

V. Phone/Fax

Practice location:
  • Phone: 516-222-5100
  • Fax:
Mailing address:
  • Phone: 845-608-3114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number062043-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: