MEDICARE: MELISSA ROSE KORNHABER DMD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	062382	NY
2	122300000X	Dentist	LL-501-19	NV

General Provider Information

NPI Number	:	1558822288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA ROSE KORNHABER DMD

Provider Business Mailing Address
First Line	:	3 FAIRWAY DR
Second Line	:
City	:	GOSHEN
State	:	NY
Zip	:	10924-6929
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1990 DEER PARK AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-3303
Country	:	US
Telephone Number	:	631-586-7654
Fax Number	:

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

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	06/09/2022

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