=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316207848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAD S HANTVERK DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 05/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2806 STEINWAY ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-932-8880
-----------------------------------------------------
Fax | 718-545-6059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2806 STEINWAY ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-932-8880
-----------------------------------------------------
Fax | 718-545-6059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. BRAD S HANTVERK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-932-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 36010
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------