Healthcare Provider Details

I. General information

NPI: 1730762642
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF BORO PARK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 50TH ST
BROOKLYN NY
11219-3745
US

IV. Provider business mailing address

10 HALYARD RD
VALLEY STREAM NY
11581-2813
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHALOM BLOBSTEIN
Title or Position: DR/OWNER
Credential: DMD
Phone: 917-450-4990