Healthcare Provider Details

I. General information

NPI: 1093454514
Provider Name (Legal Business Name): JONATHAN TAI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W 57TH ST STE 700
NEW YORK NY
10019-2303
US

IV. Provider business mailing address

119 W 57TH ST STE 700
NEW YORK NY
10019-2303
US

V. Phone/Fax

Practice location:
  • Phone: 212-751-5522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number063241
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number113537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: