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General NPI Number Information
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NPI Number | 1346790813
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Entity Type | Organization
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Legal Business Name | LIVE WELL DENTAL SERVICES PLLC
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Dates
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Enumeration Date | 10/09/2016
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Last Update Date | 10/09/2016
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Provider Practice Location Address
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Address Line | 86 PIERREPONT ST
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City | BROOKLYN
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State | NY
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Zip | 11201-2819
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Country | US
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Telephone | 718-875-8088
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Fax |
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Provider Business Mailing Address
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Address Line | 365 BRIDGE ST APT 3O
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City | BROOKLYN
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State | NY
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Zip | 11201-3802
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Country | US
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Telephone | 917-309-3961
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. DAVID TAVELIN
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Credential | DDS
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Telephone | 917-309-3961
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 50111243
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License Number State | NY
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