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General NPI Number Information
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NPI Number | 1942364005
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Entity Type | Organization
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Legal Business Name | GORDON J DIEHL DMD PC
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 06/27/2012
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Provider Practice Location Address
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Address Line | 176 GNARLED HOLLOW ROAD
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City | EAST SETAUKET
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State | NY
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Zip | 11733
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Country | US
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Telephone | 631-689-1548
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Fax | 631-689-1516
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Provider Business Mailing Address
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Address Line | 176 GNARLED HOLLOW RD
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City | EAST SETAUKET
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State | NY
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Zip | 11733
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Country | US
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Telephone | 631-689-1548
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Fax | 631-689-1516
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GORDON JOSEF DIEHL
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Credential | DMD
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Telephone | 631-689-1548
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 040755
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License Number State | NY
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