Healthcare Provider Details

I. General information

NPI: 1245271345
Provider Name (Legal Business Name): GREGORY MICHAEL FELTON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WINDCREST DR
MANORVILLE NY
11949-2922
US

IV. Provider business mailing address

1 WINDCREST DR
MANORVILLE NY
11949-2922
US

V. Phone/Fax

Practice location:
  • Phone: 631-878-7752
  • Fax:
Mailing address:
  • Phone: 631-878-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045364
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: