Provider Demographics
NPI:1902022122
Name:MIZRAHI, EMANUEL (DDS)
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:MIZRAHI
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 1:10821 69TH RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3839
Mailing Address - Country:US
Mailing Address - Phone:718-897-6666
Mailing Address - Fax:718-263-7678
Practice Address - Street 1:10821 69TH RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3839
Practice Address - Country:US
Practice Address - Phone:718-897-6666
Practice Address - Fax:718-263-7678
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042835-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01388792Medicaid