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General NPI Number Information
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NPI Number | 1073638151
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Entity Type | Organization
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Legal Business Name | ROOSEVELT FIELD MALL DENTAL PC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 630 OLD COUNTRY ROAD
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City | GARDEN CITY
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State | NY
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Zip | 11530
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Country | US
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Telephone | 516-294-1919
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Fax | 516-294-6219
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Provider Business Mailing Address
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Address Line | 630 OLD COUNTRY ROAD
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City | GARDEN CITY
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State | NY
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Zip | 11530
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Country | US
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Telephone | 516-294-1919
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Fax | 516-294-6219
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Authorized Official
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Title or Position | OWNER
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Name | ALEXANDER M MIKHAILOV
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Credential | DDS
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Telephone | 516-294-1919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | NY
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