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General NPI Number Information
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NPI Number | 1134561137
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Entity Type | Organization
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Legal Business Name | 125TH ST. DENTAL GROUP, PLLC
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Dates
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Enumeration Date | 07/19/2013
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Last Update Date | 07/19/2013
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Provider Practice Location Address
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Address Line | 63 W 125TH ST 2ND FLOOR
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City | NEW YORK
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State | NY
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Zip | 10027-4512
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Country | US
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Telephone | 646-505-8852
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Fax |
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Provider Business Mailing Address
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Address Line | 63 W 125TH ST 2ND FLOOR
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City | NEW YORK
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State | NY
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Zip | 10027-4512
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Country | US
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Telephone | 646-505-8852
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. DANIEL KUNCIO
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Credential | DDS
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Telephone | 646-505-8852
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 051019
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License Number State | NY
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