Healthcare Provider Details

I. General information

NPI: 1417317124
Provider Name (Legal Business Name): PRESTIGE FIFTH AVENUE DENTAL P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 40TH ST RM 406
NEW YORK NY
10016-1801
US

IV. Provider business mailing address

110 E 40TH ST RM 406
NEW YORK NY
10016-1801
US

V. Phone/Fax

Practice location:
  • Phone: 212-682-5060
  • Fax: 212-683-4330
Mailing address:
  • Phone: 212-682-5060
  • Fax: 212-683-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: YELENA SIMKHA
Title or Position: DDS
Credential:
Phone: 212-682-5060