=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225183551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY MALL DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BROADWAY MALL
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-933-3444
-----------------------------------------------------
Fax | 516-933-3445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 BROADWAY MALL
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-933-3444
-----------------------------------------------------
Fax | 516-933-3445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IGOR LEVIN
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 516-933-3444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------