Healthcare Provider Details

I. General information

NPI: 1326498734
Provider Name (Legal Business Name): MADISON AVENUE DENTAL CARE PLLC
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

515 MADISON AVE 3303
NEW YORK NY
10022-5403
US

IV. Provider business mailing address

515 MADISON AVE 3303
NEW YORK NY
10022-5403
US

V. Phone/Fax

Practice location:
  • Phone: 212-751-1333
  • Fax:
Mailing address:
  • Phone: 212-751-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SIMON ROYTBERG
Title or Position: MEMBER
Credential:
Phone: 201-328-7059