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General NPI Number Information
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NPI Number | 1093958282
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Entity Type | Organization
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Legal Business Name | BROOKLYN PERIODONTICS AND IMPLANT DENTISTRY, P.C.
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Dates
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Enumeration Date | 04/17/2009
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Last Update Date | 10/01/2013
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Provider Practice Location Address
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Address Line | 185 MONTAGUE ST 9TH FLOOR
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City | BROOKLYN
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State | NY
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Zip | 11201-3600
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Country | US
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Telephone | 718-643-1953
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Fax |
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Provider Business Mailing Address
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Address Line | 185 MONTAGUE ST 9TH FLOOR
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City | BROOKLYN
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State | NY
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Zip | 11201-3600
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Country | US
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Telephone | 718-643-1953
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Fax |
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. MICHAEL ZIDILE
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Credential | D.D.S.
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Telephone | 718-643-1953
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 052187
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License Number State | NY
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