Healthcare Provider Details

I. General information

NPI: 1205047693
Provider Name (Legal Business Name): MT. SINAI FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 NESCONSET HWY STE. 230
MOUNT SINAI NY
11766-2037
US

IV. Provider business mailing address

5505 NESCONSET HWY STE. 230
MOUNT SINAI NY
11766-2037
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-8989
  • Fax: 631-331-7962
Mailing address:
  • Phone: 631-331-8989
  • Fax: 631-331-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number047118
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number047078
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number048342
License Number StateNY

VIII. Authorized Official

Name: MRS. ANTOINETTE DERENZO
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-331-8989