=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235480450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW YORK ORTHODONTIC GROUP DBA JACKSON HEIGHTS ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2012
-----------------------------------------------------
Last Update Date | 09/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7409 37TH AVE SUITE 301
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-335-4444
-----------------------------------------------------
Fax | 718-335-1855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7409 37TH AVE SUITE 301
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-335-4444
-----------------------------------------------------
Fax | 718-335-1855
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. EFSTATHIOS GIANNOUTSOS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-335-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | NY052416
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------