Healthcare Provider Details

I. General information

NPI: 1699076083
Provider Name (Legal Business Name): URBAN PEDIATRIC DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MOTT STREET SUITE 203
NEW YORK NY
10013-5575
US

IV. Provider business mailing address

128 MOTT STREET SUITE 203
NEW YORK NY
10013-5575
US

V. Phone/Fax

Practice location:
  • Phone: 212-965-8113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0535941
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number0497501
License Number StateNY

VIII. Authorized Official

Name: MS. JESSICA LOO MARN
Title or Position: PRACTICE OWNER
Credential: D.D.S
Phone: 212-965-8113