=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164683215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLY DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2008
-----------------------------------------------------
Last Update Date | 06/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4279 78TH ST
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-651-2768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4279 78TH ST
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-651-2768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. THOMAS HE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-651-7273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 052906
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------