Healthcare Provider Details

I. General information

NPI: 1093295735
Provider Name (Legal Business Name): GIFFORDS DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 GIFFORDS LN
STATEN ISLAND NY
10308-2411
US

IV. Provider business mailing address

PO BOX 90081
STATEN ISLAND NY
10309-0081
US

V. Phone/Fax

Practice location:
  • Phone: 718-984-4404
  • Fax:
Mailing address:
  • Phone: 917-414-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number052816
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number059157
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number029974
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number049017
License Number StateNY

VIII. Authorized Official

Name: DR. STEVEN CISTERNAS
Title or Position: PRESIDENT
Credential: DDS
Phone: 917-414-4993