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General NPI Number Information
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NPI Number | 1316440266
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Entity Type | Organization
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Legal Business Name | PARK AVENUE DENTAL BOUTIQUE, L.L.C.
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Dates
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Enumeration Date | 03/16/2018
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Last Update Date | 03/16/2018
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Provider Practice Location Address
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Address Line | 104 E 74TH ST
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City | NEW YORK
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State | NY
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Zip | 10021-3544
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Country | US
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Telephone | 212-369-2202
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Fax |
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Provider Business Mailing Address
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Address Line | 104 E 74TH ST
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City | NEW YORK
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State | NY
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Zip | 10021-3544
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Country | US
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Telephone | 212-369-2202
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | MR. MICHAEL WARSZAWSKI
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Credential |
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Telephone | 646-455-8657
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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 | 0506391
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License Number State | NY
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