Healthcare Provider Details

I. General information

NPI: 1104352012
Provider Name (Legal Business Name): OCEAN-SIDE DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 CONEY ISLAND AVE UNIT A4
BROOKLYN NY
11235-6643
US

IV. Provider business mailing address

3260 CONEY ISLAND AVE UNIT A4
BROOKLYN NY
11235-6643
US

V. Phone/Fax

Practice location:
  • Phone: 718-891-0021
  • Fax: 718-891-4946
Mailing address:
  • Phone: 718-891-0021
  • Fax: 718-891-4946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049909-1
License Number StateNY

VIII. Authorized Official

Name: IRINA GONCHARUK
Title or Position: PRISIDENT
Credential: DDS
Phone: 718-908-0464