MEDICARE: MY DENTIST, P.C.

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	047879	NY

General Provider Information

NPI Number	:	1457405862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY DENTIST, P.C.

Provider Business Mailing Address
First Line	:	9516 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-2434
Country	:	US
Telephone Number	:	718-495-8801
Fax Number	:	718-346-9801

Provider Business Practice Location Address
First Line	:	9516 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-2434
Country	:	US
Telephone Number	:	718-495-8801
Fax Number	:	718-346-9801

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DMITRIY VOLOTSENKO
Credential	:	DDS
Telephone Number	:	718-495-8801

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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