Provider Demographics
NPI:1831518786
Name:GREGG FADER DMD, PC
Entity type:Organization
Organization Name:GREGG FADER DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:FADER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-475-0051
Mailing Address - Street 1:504 GRAND ST
Mailing Address - Street 2:SUITE M5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4182
Mailing Address - Country:US
Mailing Address - Phone:212-475-0051
Mailing Address - Fax:212-475-3279
Practice Address - Street 1:504 GRAND ST
Practice Address - Street 2:SUITE M5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4182
Practice Address - Country:US
Practice Address - Phone:212-475-0051
Practice Address - Fax:212-475-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040972122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01259301Medicaid