Healthcare Provider Details

I. General information

NPI: 1124827084
Provider Name (Legal Business Name): PAUL WERTENTEIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1714
US

IV. Provider business mailing address

991 DARTMOUTH LN
WOODMERE NY
11598-1009
US

V. Phone/Fax

Practice location:
  • Phone: 718-924-2254
  • Fax: 718-442-0189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number064520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: