Healthcare Provider Details

I. General information

NPI: 1740463561
Provider Name (Legal Business Name): PURE DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2007
Last Update Date: 12/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14748 ROOSEVELT AVE SUITE #L-6
FLUSHING NY
11354-4706
US

IV. Provider business mailing address

14748 ROOSEVELT AVE SUITE #L-6
FLUSHING NY
11354-4706
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-9555
  • Fax: 718-886-9557
Mailing address:
  • Phone: 718-886-9555
  • Fax: 718-886-9557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number049108
License Number StateNY

VIII. Authorized Official

Name: DR. JAMES E LEE
Title or Position: PRESIDENT
Credential: DDS
Phone: 718-886-9555