Healthcare Provider Details

I. General information

NPI: 1134561137
Provider Name (Legal Business Name): 125TH ST. DENTAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 W 125TH ST 2ND FLOOR
NEW YORK NY
10027-4512
US

IV. Provider business mailing address

63 W 125TH ST 2ND FLOOR
NEW YORK NY
10027-4512
US

V. Phone/Fax

Practice location:
  • Phone: 646-505-8852
  • Fax:
Mailing address:
  • Phone: 646-505-8852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number051019
License Number StateNY

VIII. Authorized Official

Name: DR. DANIEL KUNCIO
Title or Position: MEMBER
Credential: DDS
Phone: 646-505-8852