Healthcare Provider Details

I. General information

NPI: 1609852649
Provider Name (Legal Business Name): ZOOM SMILE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 ROUTE 304
NEW CITY NY
10956-2925
US

IV. Provider business mailing address

532 ROUTE 304
NEW CITY NY
10956-2925
US

V. Phone/Fax

Practice location:
  • Phone: 845-499-2006
  • Fax: 845-499-2112
Mailing address:
  • Phone: 845-499-2006
  • Fax: 845-499-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number043709
License Number StateNY

VIII. Authorized Official

Name: DR. KEITH MA
Title or Position: PRESIDENT/ DENTIST
Credential: DDS
Phone: 845-499-2006