Healthcare Provider Details

I. General information

NPI: 1003182874
Provider Name (Legal Business Name): PARK AVENUE ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 PARK AVE SUITE 102
NEW YORK NY
10028-0212
US

IV. Provider business mailing address

935 PARK AVE SUITE 102
NEW YORK NY
10028-0212
US

V. Phone/Fax

Practice location:
  • Phone: 212-452-2777
  • Fax: 212-452-3363
Mailing address:
  • Phone: 212-452-2777
  • Fax: 212-452-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number040533
License Number StateNY

VIII. Authorized Official

Name: JANET STOESS-ALLEN
Title or Position: OWNER
Credential: D.M.D
Phone: 212-452-2777