Healthcare Provider Details

I. General information

NPI: 1790242683
Provider Name (Legal Business Name): NINA POOTHIKOTTU PHILIP DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 S BROADWAY
YONKERS NY
10705-2340
US

IV. Provider business mailing address

462 S BROADWAY
YONKERS NY
10705-2340
US

V. Phone/Fax

Practice location:
  • Phone: 914-376-6138
  • Fax:
Mailing address:
  • Phone: 914-376-6138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number061468
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: