Healthcare Provider Details

I. General information

NPI: 1902343874
Provider Name (Legal Business Name): AESTHETIC AND IMPLANT DENTAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7825 4TH AVE
BROOKLYN NY
11209-3711
US

IV. Provider business mailing address

7825 4TH AVE
BROOKLYN NY
11209-3711
US

V. Phone/Fax

Practice location:
  • Phone: 718-745-0179
  • Fax:
Mailing address:
  • Phone: 718-745-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number50-050579
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number50-050579
License Number StateNY

VIII. Authorized Official

Name: JOSEPH MANISCALCO
Title or Position: OWNER
Credential: DDS
Phone: 718-745-0179