Healthcare Provider Details

I. General information

NPI: 1134189509
Provider Name (Legal Business Name): BRIAN RICHARD CIPORIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6839 MYRTLE AVE
GLENDALE NY
11385-7234
US

IV. Provider business mailing address

8808 151ST AVE 5K
HOWARD BEACH NY
11414-1440
US

V. Phone/Fax

Practice location:
  • Phone: 718-497-4585
  • Fax: 718-497-4585
Mailing address:
  • Phone: 718-845-7193
  • Fax: 718-845-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberNY039882
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401006644
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: