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General NPI Number Information
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NPI Number | 1063536787
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Entity Type | Individual
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Provider Name | THOMAS A MORTILLARO DDS
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Gender | Male
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 08/17/2020
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Provider Practice Location Address
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Address Line | 8219 12TH AVE
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City | BROOKLYN
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State | NY
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Zip | 11228-2933
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Country | US
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Telephone | 718-491-3901
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Fax |
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Provider Business Mailing Address
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Address Line | 8219 12TH AVE
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City | BROOKLYN
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State | NY
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Zip | 11228-2933
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 045148
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License Number State | NY
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