Healthcare Provider Details

I. General information

NPI: 1679010920
Provider Name (Legal Business Name): WESTCHESTER PUTNAM ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S BEDFORD RD STE 410
MOUNT KISCO NY
10549-3439
US

IV. Provider business mailing address

101 S BEDFORD RD STE 410
MOUNT KISCO NY
10549-3439
US

V. Phone/Fax

Practice location:
  • Phone: 914-241-1177
  • Fax:
Mailing address:
  • Phone: 914-241-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number028744
License Number StateNY

VIII. Authorized Official

Name: NICK MASTROMIHALIS
Title or Position: OWNER/ENDODONTIST
Credential:
Phone: 914-241-1177