Basic Information
| Provider Information | |||||||||
| NPI: | 1083691638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORI | ||||||||
| FirstName: | JUDITH | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FLETCHER ST | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109241402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452948806 | ||||||||
| FaxNumber: | 8452948650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2005 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 039611 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02640673 | 05 | NY | MEDICAID |