Provider Demographics
NPI:1063775880
Name:REDMOND, PETER WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:WILLIAM
Last Name:REDMOND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-0749
Mailing Address - Country:US
Mailing Address - Phone:631-298-9168
Mailing Address - Fax:631-298-5728
Practice Address - Street 1:7555 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-1516
Practice Address - Country:US
Practice Address - Phone:631-298-9168
Practice Address - Fax:631-298-5728
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice