Healthcare Provider Details

I. General information

NPI: 1114916897
Provider Name (Legal Business Name): GEDALYA RAPOPORT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEDICAL PARK DR
POMONA NY
10970-3516
US

IV. Provider business mailing address

8 MEDICAL PARK DR
POMONA NY
10970-3516
US

V. Phone/Fax

Practice location:
  • Phone: 845-517-2358
  • Fax: 845-517-2359
Mailing address:
  • Phone: 845-517-2358
  • Fax: 845-517-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number051857
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number051857
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: