Healthcare Provider Details

I. General information

NPI: 1437509841
Provider Name (Legal Business Name): DENTAL ANESTHESIA OF NEW YORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 53RD ST APT 126
NEW YORK NY
10019-5693
US

IV. Provider business mailing address

410 W 53RD ST APT 126
NEW YORK NY
10019-5693
US

V. Phone/Fax

Practice location:
  • Phone: 215-527-8768
  • Fax:
Mailing address:
  • Phone: 215-527-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number054360
License Number StateNY

VIII. Authorized Official

Name: DR. PHONG TA
Title or Position: DENTIST ANESTHESIOLOGIST/OWNER
Credential: DDS
Phone: 215-527-8768