Healthcare Provider Details

I. General information

NPI: 1598134801
Provider Name (Legal Business Name): RIVERDALE URGENT CARE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 JOHNSON AVE
BRONX NY
10463-1602
US

IV. Provider business mailing address

3509 JOHNSON AVE
BRONX NY
10463-1602
US

V. Phone/Fax

Practice location:
  • Phone: 914-769-0799
  • Fax: 914-769-5011
Mailing address:
  • Phone: 914-769-0799
  • Fax: 914-769-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0491001
License Number StateNY

VIII. Authorized Official

Name: SCOTT F LOESER
Title or Position: SOLE MBR
Credential: D.M.D.
Phone: 914-769-0799