Healthcare Provider Details

I. General information

NPI: 1235340472
Provider Name (Legal Business Name): ANGELA THEODORA ANDERSON D.D.S.,M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2007
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 54TH ST SUITE #1E
NEW YORK NY
10019-5404
US

IV. Provider business mailing address

300 RECTOR PL #5J
NEW YORK NY
10280-1416
US

V. Phone/Fax

Practice location:
  • Phone: 212-724-8400
  • Fax: 212-945-6219
Mailing address:
  • Phone: 212-724-8400
  • Fax: 212-945-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number044932
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: