Healthcare Provider Details

I. General information

NPI: 1225468432
Provider Name (Legal Business Name): TOTAL DENTAL CARE OF STATEN ISLAND, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 WILLOWBROOK ROAD
STATEN ISLAND NY
10302
US

IV. Provider business mailing address

135 WILLOWBROOK ROAD
STATEN ISLAND NY
10302
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-1144
  • Fax: 718-815-9028
Mailing address:
  • Phone: 718-448-1144
  • Fax: 718-815-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50055536
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number051010
License Number StateNY

VIII. Authorized Official

Name: ADAM LYLE ZATCOFF
Title or Position: OWNER
Credential: DMD
Phone: 718-448-1144