Healthcare Provider Details

I. General information

NPI: 1538441993
Provider Name (Legal Business Name): TERRY BRUCE MOPPER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 GRASMERE DR
STATEN ISLAND NY
10305-2848
US

IV. Provider business mailing address

322 GRASMERE DR
STATEN ISLAND NY
10305-2848
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-4680
  • Fax:
Mailing address:
  • Phone: 718-442-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29636
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: