Provider Demographics
NPI:1962733238
Name:ADVANCED DENTISTRY OF TARRYTOWN
Entity type:Organization
Organization Name:ADVANCED DENTISTRY OF TARRYTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:914-332-4402
Mailing Address - Street 1:42 WILDEY ST
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-3109
Mailing Address - Country:US
Mailing Address - Phone:914-332-4402
Mailing Address - Fax:914-332-4429
Practice Address - Street 1:42 WILDEY ST
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-3109
Practice Address - Country:US
Practice Address - Phone:914-332-4402
Practice Address - Fax:914-332-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048-4501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty