=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215150727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYSIDE DENTAL ASSOCIATES LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2391 BELL BLVD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-631-7337
-----------------------------------------------------
Fax | 718-428-0431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2391 BELL BLVD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-631-7337
-----------------------------------------------------
Fax | 718-428-0431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. PAUL GRUNSEICH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-631-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------