MEDICARE: APEX DENTAL, PC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	051170-1	NY
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	049449-1	NY
3	125J00000X	Dental Therapist	052602	NY
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	052799	NY

General Provider Information

NPI Number	:	1639570278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APEX DENTAL, PC

Provider Business Mailing Address
First Line	:	7407 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7433
Country	:	US
Telephone Number	:	718-497-9700
Fax Number	:

Provider Business Practice Location Address
First Line	:	7407 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7433
Country	:	US
Telephone Number	:	718-497-9700
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SURGEON
Name	:	ANTOINE J PANOSSIAN
Credential	:	DMD
Telephone Number	:	718-497-9700

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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