Healthcare Provider Details

I. General information

NPI: 1255322061
Provider Name (Legal Business Name): CITY DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BROADWAY MEZAN. LEVEL
NEW YORK NY
10004-1303
US

IV. Provider business mailing address

11 BROADWAY MEZAN. LEVEL
NEW YORK NY
10004-1303
US

V. Phone/Fax

Practice location:
  • Phone: 212-425-0505
  • Fax: 212-425-2120
Mailing address:
  • Phone: 212-425-0505
  • Fax: 212-425-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number049110-1
License Number StateNY

VIII. Authorized Official

Name: STEVE TARANOV
Title or Position: DDS
Credential: DDS
Phone: 212-425-0505