Healthcare Provider Details

I. General information

NPI: 1841289170
Provider Name (Legal Business Name): PARK DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 63RD DR
REGO PARK NY
11374-3849
US

IV. Provider business mailing address

9101 63RD DR
REGO PARK NY
11374-3849
US

V. Phone/Fax

Practice location:
  • Phone: 718-565-5445
  • Fax: 718-565-0952
Mailing address:
  • Phone: 718-565-5445
  • Fax: 718-565-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number044129-1
License Number StateNY

VIII. Authorized Official

Name: MR. OLEG P KLEMPNER
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 718-565-5445