MEDICARE: GY 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	1223G0001X	General Practice Dentistry	049312	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790900785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GY DENTAL PC

Provider Business Mailing Address
First Line	:	99-46 62 DRIVE
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374
Country	:	US
Telephone Number	:	718-421-6300
Fax Number	:	718-421-6001

Provider Business Practice Location Address
First Line	:	1419 FOSTER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1726
Country	:	US
Telephone Number	:	718-421-6300
Fax Number	:	718-421-6001

Authorized Official
Title or Position	:	DDS GENERAL DENTIST
Name	:	GRIGORIY YUSUPOV
Credential	:	DDS
Telephone Number	:	718-421-6300

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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Directions to “GY DENTAL PC ” Practice Location

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