Healthcare Provider Details

I. General information

NPI: 1114551587
Provider Name (Legal Business Name): REBECCA ELLERIN GRODKO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ELLERIN DAVID

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

596 S FOREST DR
TEANECK NJ
07666-2011
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 617-938-9189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number061920
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: