=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194149674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGETOWNDENTALSPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2014
-----------------------------------------------------
Last Update Date | 02/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2167 RALPH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-676-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2167 RALPH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-5405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-676-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANDREW MARON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-676-7700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 043641
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------