Healthcare Provider Details

I. General information

NPI: 1700469244
Provider Name (Legal Business Name): JONAH PETER SPAETH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/18/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 NY-112 BLDG 6 SUITE 7B
MEDFORD NY
11763
US

IV. Provider business mailing address

3237 NY-112 BLDG 6 SUITE 7B
MEDFORD NY
11763
US

V. Phone/Fax

Practice location:
  • Phone: 631-320-0880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number063505
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: