Healthcare Provider Details

I. General information

NPI: 1194728196
Provider Name (Legal Business Name): GAIL ELLEN SCHUPAK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CENTRAL PARK S SUITE 6C
NEW YORK NY
10019-1628
US

IV. Provider business mailing address

30 CENTRAL PARK SOUTH SUITE 6C
NEW YORK NY
10019-1628
US

V. Phone/Fax

Practice location:
  • Phone: 212-753-5540
  • Fax: 212-980-8466
Mailing address:
  • Phone: 212-753-5540
  • Fax: 212-980-8466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number037952
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: