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General NPI Number Information
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NPI Number | 1265076186
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Entity Type | Organization
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Legal Business Name | OM DENTAL ARTS, PLLC
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Dates
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Enumeration Date | 11/04/2019
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Last Update Date | 11/04/2019
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Provider Practice Location Address
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Address Line | 405 LEXINGTON AVE FL 54
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City | NEW YORK
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State | NY
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Zip | 10174-0002
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Country | US
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Telephone | 212-661-9777
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Fax |
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Provider Business Mailing Address
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Address Line | 1725 SHEEPSHEAD BAY RD
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City | BROOKLYN
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State | NY
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Zip | 11235-3606
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. OLGA DEGTYAREVA
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Credential | DDS
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Telephone | 917-306-9086
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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