Healthcare Provider Details

I. General information

NPI: 1568500031
Provider Name (Legal Business Name): MARTIN JAY THALER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 BARTLETT RD
MONSEY NY
10952-1707
US

IV. Provider business mailing address

14 BARTLETT RD
MONSEY NY
10952-1707
US

V. Phone/Fax

Practice location:
  • Phone: 845-425-7655
  • Fax: 845-425-7527
Mailing address:
  • Phone: 845-425-7655
  • Fax: 845-425-7527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37408
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: