=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134648223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL LITUCHY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2017
-----------------------------------------------------
Last Update Date | 07/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 CENTRAL PARK S
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-586-2612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 W 20TH ST APT 8R
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-770-0334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 059404
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------