Healthcare Provider Details

I. General information

NPI: 1396376356
Provider Name (Legal Business Name): I. PRODANOVA DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W 34TH ST RM 903
NEW YORK NY
10001-2229
US

IV. Provider business mailing address

241 W 97TH ST APT 2N
NEW YORK NY
10025-6207
US

V. Phone/Fax

Practice location:
  • Phone: 212-216-9090
  • Fax:
Mailing address:
  • Phone: 646-387-6083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. IORDANKA PRODANOVA
Title or Position: DENTIST
Credential:
Phone: 212-216-9092