Healthcare Provider Details

I. General information

NPI: 1770803728
Provider Name (Legal Business Name): RODERICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 E 4TH ST
NEW YORK NY
10009-7522
US

IV. Provider business mailing address

254 E 4TH ST
NEW YORK NY
10009-7522
US

V. Phone/Fax

Practice location:
  • Phone: 212-777-1969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number052771
License Number StateNY

VIII. Authorized Official

Name: DR. RODERICK AMAN LUCENTE
Title or Position: DENTIST
Credential:
Phone: 212-777-1969