Provider Demographics
NPI:1093396509
Name:DANIEL, REBECCA SUSAN (DDS)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUSAN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1920
Mailing Address - Country:US
Mailing Address - Phone:914-819-2571
Mailing Address - Fax:
Practice Address - Street 1:20 MILLPOND PKWY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3565
Practice Address - Country:US
Practice Address - Phone:845-783-8741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0625191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program