Healthcare Provider Details

I. General information

NPI: 1043632318
Provider Name (Legal Business Name): ELITE DENTAL OF STATEN ISLAND,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2291 VICTORY BLVD
STATEN ISLAND NY
10314-6625
US

IV. Provider business mailing address

2291 VICTORY BLVD
STATEN ISLAND NY
10314-6625
US

V. Phone/Fax

Practice location:
  • Phone: 718-370-1200
  • Fax: 718-370-1207
Mailing address:
  • Phone: 718-370-1200
  • Fax: 718-370-1207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number036474
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN R ACKER
Title or Position: OWNER
Credential: DDS
Phone: 718-370-1200