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General NPI Number Information
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NPI Number | 1114332798
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Entity Type | Organization
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Legal Business Name | OPEN DENTAL PC
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Dates
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Enumeration Date | 06/23/2014
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Last Update Date | 06/23/2014
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Provider Practice Location Address
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Address Line | 300 E 96TH ST APT 6E
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City | NEW YORK
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State | NY
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Zip | 10128-3869
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Country | US
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Telephone | 734-883-4406
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Fax |
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Provider Business Mailing Address
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Address Line | 300 E 96TH ST APT 6E
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City | NEW YORK
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State | NY
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Zip | 10128-3869
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Country | US
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Telephone | 734-883-4406
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ANASTASIA KOVALEVA
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Credential |
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Telephone | 718-618-7564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 056676
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License Number State | NY
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