Healthcare Provider Details

I. General information

NPI: 1538570585
Provider Name (Legal Business Name): MADISON AVENUE ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MADISON AVE
NEW YORK NY
10035-2700
US

IV. Provider business mailing address

15 ENGLE ST
ENGLEWOOD NJ
07631-2936
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-7300
  • Fax: 212-996-7301
Mailing address:
  • Phone: 201-308-8181
  • Fax: 718-373-6799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number047218
License Number StateNY

VIII. Authorized Official

Name: DR. OLEG DRUT
Title or Position: DOCTOR
Credential:
Phone: 212-996-7300