Healthcare Provider Details

I. General information

NPI: 1639648819
Provider Name (Legal Business Name): ISAAC DATIKASHVILI DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2018
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 12TH ST
NEW YORK NY
10003-5375
US

IV. Provider business mailing address

100 E 12TH ST
NEW YORK NY
10003-5375
US

V. Phone/Fax

Practice location:
  • Phone: 212-600-4274
  • Fax:
Mailing address:
  • Phone: 212-600-4274
  • 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 Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. ISAAC DATIKASHVILI
Title or Position: CHIEF DOCTOR
Credential: DMD
Phone: 215-917-6886