Healthcare Provider Details

I. General information

NPI: 1457758963
Provider Name (Legal Business Name): BRANDON CARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 CLINTON ST
HEMPSTEAD NY
11550-2600
US

IV. Provider business mailing address

45 W 132ND ST APT 2M
NEW YORK NY
10037-3101
US

V. Phone/Fax

Practice location:
  • Phone: 516-483-8136
  • Fax:
Mailing address:
  • Phone: 919-368-5490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number058310
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: