Healthcare Provider Details

I. General information

NPI: 1205229044
Provider Name (Legal Business Name): BROOKLYN SMILE DENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9412 4TH AVE
BROOKLYN NY
11209-7301
US

IV. Provider business mailing address

9412 4TH AVE
BROOKLYN NY
11209-7301
US

V. Phone/Fax

Practice location:
  • Phone: 718-745-3456
  • Fax: 718-745-3205
Mailing address:
  • Phone: 718-745-3456
  • Fax: 718-745-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number46724
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number36187
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36187
License Number StateNY

VIII. Authorized Official

Name: DR. GARY HERSKOVITS
Title or Position: DENTIST
Credential: DDS
Phone: 718-745-3456