Healthcare Provider Details

I. General information

NPI: 1376268821
Provider Name (Legal Business Name): WHITE HALL DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

IV. Provider business mailing address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7110
  • Fax: 718-470-7393
Mailing address:
  • Phone: 718-470-7110
  • Fax: 718-470-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SHARLENE BRONSTORPH
Title or Position: DIRECTOR
Credential:
Phone: 516-850-3999