Healthcare Provider Details

I. General information

NPI: 1205970332
Provider Name (Legal Business Name): DISTINCTIVE DENTAL SERVICES OF NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 E SHORE RD SUITE 201
GREAT NECK NY
11023-2415
US

IV. Provider business mailing address

173 EAST SHORE RD SUITE 201
GREAT NECK NY
11023
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-8110
  • Fax: 516-487-8394
Mailing address:
  • Phone: 516-487-8110
  • Fax: 516-487-8394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number054882
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number34227
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number054882
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RALPH HARRIS EPSTEIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 516-487-8110