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General NPI Number Information
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NPI Number | 1124232970
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Entity Type | Organization
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Legal Business Name | PARK WEST DENTAL PC
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 200 CENTRAL PARK S SUITE 102
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City | NEW YORK
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State | NY
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Zip | 10019-1436
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Country | US
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Telephone | 212-757-1370
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Fax | 212-757-2819
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Provider Business Mailing Address
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Address Line | 200 CENTRAL PARK S SUITE 102
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City | NEW YORK
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State | NY
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Zip | 10019-1436
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Country | US
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Telephone | 212-757-1370
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Fax | 212-757-2819
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEROME S LUSTBADER
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Credential | DMD
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Telephone | 212-757-1370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 033896
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License Number State | NY
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