Healthcare Provider Details

I. General information

NPI: 1154549194
Provider Name (Legal Business Name): JEFFREY MARMOR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 RT. 32
HIGHLAND MILLS NY
10930
US

IV. Provider business mailing address

PO BOX 595
HIGHLAND MILLS NY
10930-0595
US

V. Phone/Fax

Practice location:
  • Phone: 845-928-2353
  • Fax:
Mailing address:
  • Phone: 845-928-2353
  • Fax: 845-928-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number039342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: