Healthcare Provider Details

I. General information

NPI: 1467574871
Provider Name (Legal Business Name): IDEAL DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 NORTHERN BOULEVARD SUITE #6
GREAT NECK NY
11021
US

IV. Provider business mailing address

800 NORTHERN BOULEVARD SUITE #6
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-6453
  • Fax:
Mailing address:
  • Phone: 516-487-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047563
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number047563
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number047563
License Number StateNY

VIII. Authorized Official

Name: DR. PANAGIOTIS GLAVAS
Title or Position: OWNER
Credential: DDS
Phone: 516-487-6453