Healthcare Provider Details

I. General information

NPI: 1013937143
Provider Name (Legal Business Name): PRASAD CHILDREN'S DENTAL HEATH PROGRAM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 BRICKMAN RD
HURLEYVILLE NY
12747-6002
US

IV. Provider business mailing address

465 BRICKMAN RD
HURLEYVILLE NY
12747-5314
US

V. Phone/Fax

Practice location:
  • Phone: 845-434-0376
  • Fax: 845-434-1791
Mailing address:
  • Phone: 845-434-0376
  • Fax: 845-434-1791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5254200R
License Number StateNY

VIII. Authorized Official

Name: DR. MARIA CECILIA ESCARRA
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 845-434-0376