Healthcare Provider Details

I. General information

NPI: 1003338674
Provider Name (Legal Business Name): NEIGHBORHOOD DENTAL OF BUSHWICK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 KNICKERBOCKER AVE
BROOKLYN NY
11237
US

IV. Provider business mailing address

291 KNICKERBOCKER AVE
BROOKLYN NY
11237-3103
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-9500
  • Fax:
Mailing address:
  • Phone: 718-963-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. OLGA MIHNYONOK
Title or Position: OFFICER
Credential:
Phone: 718-963-9500