MEDICARE: BOYNTON 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	041973	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952573594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYNTON DENTAL,PC

Provider Business Mailing Address
First Line	:	1537 WESTCHESTER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10472-2908
Country	:	US
Telephone Number	:	718-617-0624
Fax Number	:	718-328-3887

Provider Business Practice Location Address
First Line	:	1537 WESTCHESTER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10472-2908
Country	:	US
Telephone Number	:	718-617-0624
Fax Number	:	718-328-3887

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMY FATOUH
Credential	:
Telephone Number	:	718-617-0624

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	03/24/2008

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Directions to “BOYNTON DENTAL,PC ” Practice Location

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