Healthcare Provider Details

I. General information

NPI: 1437523867
Provider Name (Legal Business Name): 63RD STREET DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8A E 63RD ST
NEW YORK NY
10065-7210
US

IV. Provider business mailing address

8A E 63RD ST
NEW YORK NY
10065-7210
US

V. Phone/Fax

Practice location:
  • Phone: 212-355-2540
  • Fax:
Mailing address:
  • Phone: 212-355-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number045975-1
License Number StateNY

VIII. Authorized Official

Name: DR. LANA ROZENBERG
Title or Position: OWNER
Credential:
Phone: 212-355-2540