Healthcare Provider Details

I. General information

NPI: 1417135211
Provider Name (Legal Business Name): QUEENS SMILE DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-76 QUEENS BLVD # 1 E
REGO PARK NY
11374-4300
US

IV. Provider business mailing address

98-76 QUEENS BLVD # 1 E
REGO PARK NY
11374-4300
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-0591
  • Fax: 718-275-1355
Mailing address:
  • Phone: 718-459-0591
  • Fax: 718-275-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047357
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number047357
License Number StateNY

VIII. Authorized Official

Name: DR. OLGA ZAVULUNOVA
Title or Position: OWNER
Credential: D.D.S.
Phone: 718-459-0591