Healthcare Provider Details

I. General information

NPI: 1710999438
Provider Name (Legal Business Name): FIFTH AVENUE DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 5TH AVE # 1
BROOKLYN NY
11220-1207
US

IV. Provider business mailing address

4607 5TH AVE # 1
BROOKLYN NY
11220-1207
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-3191
  • Fax: 718-272-4688
Mailing address:
  • Phone: 718-854-3191
  • Fax: 718-272-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number033327
License Number StateNY

VIII. Authorized Official

Name: DR. VIRENDRA SHAH
Title or Position: DENTIST
Credential: DDS
Phone: 718-854-3191