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General NPI Number Information
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NPI Number | 1255670196
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Entity Type | Organization
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Legal Business Name | BLVD PLAZA DENTAL PC
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Dates
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Enumeration Date | 02/13/2013
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Last Update Date | 02/13/2013
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Provider Practice Location Address
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Address Line | 4221 FRANCIS LEWIS BLVD
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City | BAYSIDE
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State | NY
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Zip | 11361-2573
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Country | US
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Telephone | 718-279-8202
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Fax | 718-279-8205
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Provider Business Mailing Address
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Address Line | 4221 FRANCIS LEWIS BLVD
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City | BAYSIDE
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State | NY
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Zip | 11361-2573
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Country | US
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Telephone | 718-279-8202
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Fax | 718-279-8205
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHRISTOPHER GEORGE MIHALIOS
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Credential | DDS
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Telephone | 718-279-8202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0557791
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 052418-1
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License Number State | NY
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