=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285187872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY MODERN DENTISTRY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2016
-----------------------------------------------------
Last Update Date | 07/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 MADISON AVE SUITE 4C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10173-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-764-2229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6416 ASQUITH CRES
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-5016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DMITRY MALAYEV
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 212-764-2229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 057457
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------