Healthcare Provider Details

I. General information

NPI: 1669660031
Provider Name (Legal Business Name): 810 DENTAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 PELHAM PKWY S STE. A
BRONX NY
10462-1143
US

IV. Provider business mailing address

810 PELHAM PKWY S STE. A
BRONX NY
10462-1143
US

V. Phone/Fax

Practice location:
  • Phone: 718-824-4383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049286
License Number StateNY

VIII. Authorized Official

Name: DR. REUVEN D MOHL
Title or Position: PRESIDENT
Credential: DDS
Phone: 718-824-4383