Healthcare Provider Details

I. General information

NPI: 1245202407
Provider Name (Legal Business Name): GERALD JOSEPH KOWITT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GLENRICH DR
ST JAMES NY
11780-1610
US

IV. Provider business mailing address

1 GLENRICH DR
ST JAMES NY
11780-1610
US

V. Phone/Fax

Practice location:
  • Phone: 631-724-3535
  • Fax: 631-724-3012
Mailing address:
  • Phone: 631-724-3535
  • Fax: 631-724-3012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: