Healthcare Provider Details

I. General information

NPI: 1699922088
Provider Name (Legal Business Name): HOLLIS ADVANCED DENTAL CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19002 JAMAICA AVE 2 FLOOR
HOLLIS NY
11423-2516
US

IV. Provider business mailing address

19002 JAMAICA AVE 2 FLOOR
HOLLIS NY
11423-2516
US

V. Phone/Fax

Practice location:
  • Phone: 718-454-7418
  • Fax: 718-217-2657
Mailing address:
  • Phone: 718-454-7418
  • Fax: 718-217-2657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNY

VIII. Authorized Official

Name: DR. BENJAMIN V KATAYEV
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 718-454-7418