Healthcare Provider Details

I. General information

NPI: 1861642076
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATES OF BAYSIDE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58-47 FRANCIS LEWIS BLVD SUITE 12
BAYSIDE NY
11364-1601
US

IV. Provider business mailing address

58-47 FRANCIS LEWIS BLVD SUITE 12
BAYSIDE NY
11364-1601
US

V. Phone/Fax

Practice location:
  • Phone: 718-224-4000
  • Fax: 718-224-1921
Mailing address:
  • Phone: 718-224-4000
  • Fax: 718-224-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number047274
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number032322
License Number StateNY

VIII. Authorized Official

Name: MS. NANCY PANAGOPOULOS
Title or Position: OFFICE MANAGER
Credential:
Phone: 718-224-4000