Healthcare Provider Details

I. General information

NPI: 1720156870
Provider Name (Legal Business Name): BLUESTAR DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 ROCKAWAY PKWY
BROOKLYN NY
11236-5802
US

IV. Provider business mailing address

2110 ROCKAWAY PKWY
BROOKLYN NY
11236-5802
US

V. Phone/Fax

Practice location:
  • Phone: 718-209-8500
  • Fax: 718-942-4582
Mailing address:
  • Phone: 718-209-8500
  • Fax: 718-942-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number049803-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number047926-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049832-1
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL R DAGOSTINO
Title or Position: DIRECTOR OF DENTAL AND ORAL MED
Credential: DDS
Phone: 718-209-8500