Provider Demographics
NPI:1386935112
Name:AUSTIN, CATRISE
Entity type:Individual
Prefix:
First Name:CATRISE
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 15TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1914
Mailing Address - Country:US
Mailing Address - Phone:212-262-6054
Mailing Address - Fax:212-765-2831
Practice Address - Street 1:119 W 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2303
Practice Address - Country:US
Practice Address - Phone:212-262-6054
Practice Address - Fax:212-765-2831
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1024671001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI03229141Medicaid