=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306068598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IOANNA GEORGIA MENTZELOPOULOU D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 E 40TH ST RM 503
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-986-2039
-----------------------------------------------------
Fax | 212-532-2726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3238 42ND ST APT 1
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-767-2483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 049599
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------