Healthcare Provider Details

I. General information

NPI: 1205798030
Provider Name (Legal Business Name): BROOKLYN DENTAL HOME PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 82ND ST FL 2
JACKSON HEIGHTS NY
11372-7031
US

IV. Provider business mailing address

2120 OCEAN AVE
BROOKLYN NY
11229-1426
US

V. Phone/Fax

Practice location:
  • Phone: 718-703-7500
  • Fax:
Mailing address:
  • Phone: 718-645-1588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: ARIEL AMINOV
Title or Position: DIRECTOR
Credential:
Phone: 516-512-3164