MEDICARE: DR. MICHAEL J WEISS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	037498-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	311452422	OTHER	NY	TAX ID

General Provider Information

NPI Number	:	1306821681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J WEISS DDS

Provider Business Mailing Address
First Line	:	5940 QUEENS BLVD
Second Line	:
City	:	WOODSIDE
State	:	NY
Zip	:	11377-7758
Country	:	US
Telephone Number	:	718-651-6155
Fax Number	:	718-533-8704

Provider Business Practice Location Address
First Line	:	4109 9TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11232-4001
Country	:	US
Telephone Number	:	718-435-6858
Fax Number	:	718-435-5017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	07/26/2012

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