Healthcare Provider Details

I. General information

NPI: 1487131009
Provider Name (Legal Business Name): SOUTH END DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S END AVE STE 1B
NEW YORK NY
10280-1014
US

IV. Provider business mailing address

375 S END AVE STE 1B
NEW YORK NY
10280-1014
US

V. Phone/Fax

Practice location:
  • Phone: 212-786-0930
  • Fax: 212-656-1430
Mailing address:
  • Phone: 212-786-0930
  • Fax: 212-656-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateNY

VIII. Authorized Official

Name: STEPHANIE ARIAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 212-786-0930