Healthcare Provider Details

I. General information

NPI: 1053689463
Provider Name (Legal Business Name): GRAND DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 GRAND AVE
NORTH BALDWIN NY
11510-2811
US

IV. Provider business mailing address

2000 GRAND AVE
NORTH BALDWIN NY
11510-2811
US

V. Phone/Fax

Practice location:
  • Phone: 516-378-1968
  • Fax: 516-608-9319
Mailing address:
  • Phone: 516-378-1968
  • Fax: 516-608-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046215
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number052129
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberP82633
License Number StateNY

VIII. Authorized Official

Name: DR. FLORA ANGELA CHAVEZ-ROMERO
Title or Position: PRESIDENT
Credential: DDS
Phone: 516-378-1968