Healthcare Provider Details

I. General information

NPI: 1477765709
Provider Name (Legal Business Name): BEN MOKHTAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172-19B HILLSIDE AVE
JAMAICA NY
11432
US

IV. Provider business mailing address

17219B HILLSIDE AVE
JAMAICA NY
11432-4643
US

V. Phone/Fax

Practice location:
  • Phone: 718-739-0900
  • Fax: 718-739-7001
Mailing address:
  • Phone: 718-739-0900
  • Fax: 718-739-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046751
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: