Healthcare Provider Details

I. General information

NPI: 1831518786
Provider Name (Legal Business Name): GREGG FADER DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 GRAND ST SUITE M5
NEW YORK NY
10002-4182
US

IV. Provider business mailing address

504 GRAND ST SUITE M5
NEW YORK NY
10002-4182
US

V. Phone/Fax

Practice location:
  • Phone: 212-475-0051
  • Fax: 212-475-3279
Mailing address:
  • Phone: 212-475-0051
  • Fax: 212-475-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number040972
License Number StateNY

VIII. Authorized Official

Name: DR. GREGG FADER
Title or Position: OWNER
Credential: DMD
Phone: 212-475-0051