MEDICARE: ROSSARIN MITSUMOTO D.D.S., P.C.

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1316467269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSSARIN MITSUMOTO D.D.S., P.C.

Provider Business Mailing Address
First Line	:	245 N BROADWAY STE 108
Second Line	:
City	:	SLEEPY HOLLOW
State	:	NY
Zip	:	10591-2657
Country	:	US
Telephone Number	:	914-332-1272
Fax Number	:	914-332-1261

Provider Business Practice Location Address
First Line	:	245 N BROADWAY STE 108
Second Line	:
City	:	SLEEPY HOLLOW
State	:	NY
Zip	:	10591-2657
Country	:	US
Telephone Number	:	914-332-1272
Fax Number	:	914-332-1261

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROSSARIN MITSUMOTO
Credential	:	DDS
Telephone Number	:	914-332-1272

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	06/16/2018

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