Healthcare Provider Details

I. General information

NPI: 1023575982
Provider Name (Legal Business Name): PROHEALTH DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16345 CROSSBAY BLVD
HOWARD BEACH NY
11414-3741
US

IV. Provider business mailing address

3333 NEW HYDE PARK RD STE 310
NEW HYDE PARK NY
11042-1205
US

V. Phone/Fax

Practice location:
  • Phone: 718-641-3838
  • Fax:
Mailing address:
  • Phone: 516-654-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NATALYA KOROBEYNYK
Title or Position: RCM
Credential:
Phone: 516-654-4400