Healthcare Provider Details

I. General information

NPI: 1255670196
Provider Name (Legal Business Name): BLVD PLAZA DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 FRANCIS LEWIS BLVD
BAYSIDE NY
11361-2573
US

IV. Provider business mailing address

4221 FRANCIS LEWIS BLVD
BAYSIDE NY
11361-2573
US

V. Phone/Fax

Practice location:
  • Phone: 718-279-8202
  • Fax: 718-279-8205
Mailing address:
  • Phone: 718-279-8202
  • Fax: 718-279-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number052418-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0557791
License Number StateNY

VIII. Authorized Official

Name: DR. CHRISTOPHER GEORGE MIHALIOS
Title or Position: OWNER
Credential: DDS
Phone: 718-279-8202