Healthcare Provider Details

I. General information

NPI: 1669428041
Provider Name (Legal Business Name): PETHAN TIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 GRAND CONCOURSE
BRONX NY
10457-5221
US

IV. Provider business mailing address

120 W 86TH ST
NEW YORK NY
10024-4021
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-6347
  • Fax: 718-583-8047
Mailing address:
  • Phone: 917-714-7593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: