Healthcare Provider Details

I. General information

NPI: 1083932008
Provider Name (Legal Business Name): KG HOLLYWOOD SMILE DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DIAMOND STREET
BROOKLYN NY
11222
US

IV. Provider business mailing address

2 DIAMOND STREET
BROOKLYN NY
11222-2508
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-5900
  • Fax: 947-271-3011
Mailing address:
  • Phone: 718-299-5900
  • Fax: 947-271-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTINA GABRILYANTS
Title or Position: PRESIDENT
Credential:
Phone: 718-299-5900