Healthcare Provider Details

I. General information

NPI: 1437372380
Provider Name (Legal Business Name): PAVEL NIDERMAN D.D.S ATLANTIC DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 LEXINGTON AVE FRNT 2
NEW YORK NY
10035-1759
US

IV. Provider business mailing address

2060 LEXINGTON AVE FL 2ND
NEW YORK NY
10035-1759
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-5996
  • Fax: 212-996-0030
Mailing address:
  • Phone: 212-996-5996
  • Fax: 212-996-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number044976
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number044976
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number048519
License Number StateNY

VIII. Authorized Official

Name: DR. PAVEL NIDERMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 212-996-5996