=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316953045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARS DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 E BROADWAY # 6/FL
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002-6868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-274-8658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 52 E BROADWAY # 6/FL
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002-6868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-274-8658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | ANGELA LO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-274-8658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 047068
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------