Provider Demographics
NPI:1043953581
Name:WEBBER, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:WEBBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 E 78TH ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1502 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075
Practice Address - Country:US
Practice Address - Phone:646-864-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2024-05-21
Deactivation Date:2023-08-21
Deactivation Code:
Reactivation Date:2023-10-05
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY063366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program