Healthcare Provider Details

I. General information

NPI: 1255701959
Provider Name (Legal Business Name): PROHEALTH DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PRO HEALTH PLZ SUITE 115
NEW HYDE PARK NY
11042
US

IV. Provider business mailing address

3333 NEW HYDE PARK RD STE 310
NEW HYDE PARK NY
11042-1205
US

V. Phone/Fax

Practice location:
  • Phone: 516-467-8191
  • Fax: 516-467-8192
Mailing address:
  • Phone: 516-654-4400
  • Fax: 516-467-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number055531
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number042857
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number057838
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number053382
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number055400
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number037623
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number043834
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number036753
License Number StateNY
# 10
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number049846
License Number StateNY
# 11
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number037989
License Number StateNY

VIII. Authorized Official

Name: NATALYA KOROBEYNYK
Title or Position: RCM
Credential:
Phone: 516-654-4400