=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467010561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS MONA GHADAMI DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 631 COMMACK RD
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725-5400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-499-0531
-----------------------------------------------------
Fax | 631-231-0561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 SADDLE LN
-----------------------------------------------------
City | ROSLYN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11577-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-661-7803
-----------------------------------------------------
Fax | 516-354-4845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 061451
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------