Healthcare Provider Details

I. General information

NPI: 1801092341
Provider Name (Legal Business Name): MONTEFIORE DENTAL DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 POPLAR ST
BRONX NY
10461-2653
US

IV. Provider business mailing address

PO BOX 4156
NEW YORK NY
10261-4156
US

V. Phone/Fax

Practice location:
  • Phone: 888-700-6623
  • Fax: 718-515-5419
Mailing address:
  • Phone: 718-920-4168
  • Fax: 718-515-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES BROCKETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-920-4167