Healthcare Provider Details

I. General information

NPI: 1275274060
Provider Name (Legal Business Name): MEISA KEIVANI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 MONTAUK HWY
SPEONK NY
11972-2501
US

IV. Provider business mailing address

PO BOX 497
SPEONK NY
11972-0497
US

V. Phone/Fax

Practice location:
  • Phone: 631-325-0731
  • Fax:
Mailing address:
  • Phone: 631-325-0731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberETN745
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number063584
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: