=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134324254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD STEPHEN KONDAK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 3RD ST 19-20 STERLINGTON COMMONS
-----------------------------------------------------
City | GREENPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11944-1640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-477-1177
-----------------------------------------------------
Fax | 631-477-1175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 98
-----------------------------------------------------
City | GREENPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11944-0098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-477-1177
-----------------------------------------------------
Fax | 631-477-1175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 035632
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------