Healthcare Provider Details

I. General information

NPI: 1821204165
Provider Name (Legal Business Name): 500 OCEAN DENTAL,P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 COVE LN APT 5C
BROOKLYN NY
11234-5846
US

IV. Provider business mailing address

29 COVE LN APT 5C
BROOKLYN NY
11234-5846
US

V. Phone/Fax

Practice location:
  • Phone: 917-815-8112
  • Fax:
Mailing address:
  • Phone: 917-815-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049664
License Number StateNY

VIII. Authorized Official

Name: DR. LEONID MESAMED
Title or Position: PRESIDENT
Credential:
Phone: 917-815-8112