Healthcare Provider Details

I. General information

NPI: 1609913748
Provider Name (Legal Business Name): MARILYN TESSEL R.D.H
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN PRAGER

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WILBUR ROAD
THIELLS NY
10984
US

IV. Provider business mailing address

176 PINEVIEW AVE
BARDONIA NY
10954-1431
US

V. Phone/Fax

Practice location:
  • Phone: 845-947-6206
  • Fax: 845-947-6209
Mailing address:
  • Phone: 845-633-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number016630-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: