=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053955260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYVIEW ORTHODONTICS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2019
-----------------------------------------------------
Last Update Date | 10/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21333 39TH AVE STE 300
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-2092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-423-2626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21333 39TH AVE STE 300
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-2092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-423-2626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ORTHODONTIST
-----------------------------------------------------
Name | INESSA KANDOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-423-2626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------