MEDICARE: AVENUE D DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1396426177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUE D DENTAL PLLC

Provider Business Mailing Address
First Line	:	4401 AVENUE D
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5725
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 AVENUE D
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5725
Country	:	US
Telephone Number	:	718-451-1888
Fax Number	:

Authorized Official
Title or Position	:	RCM MANAGER
Name	:	KAREN MEDINA
Credential	:
Telephone Number	:	718-763-0505

Provider Enumeration Date	:	07/26/2023
Last Update Date	:	07/26/2023

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