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General NPI Number Information
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NPI Number | 1437509841
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Entity Type | Organization
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Legal Business Name | DENTAL ANESTHESIA OF NEW YORK, LLC
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Dates
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Enumeration Date | 06/16/2016
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Last Update Date | 06/16/2016
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Provider Practice Location Address
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Address Line | 410 W 53RD ST APT 126
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City | NEW YORK
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State | NY
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Zip | 10019-5693
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Country | US
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Telephone | 215-527-8768
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Fax |
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Provider Business Mailing Address
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Address Line | 410 W 53RD ST APT 126
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City | NEW YORK
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State | NY
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Zip | 10019-5693
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Country | US
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Telephone | 215-527-8768
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Fax |
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Authorized Official
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Title or Position | DENTIST ANESTHESIOLOGIST/OWNER
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Name | DR. PHONG TA
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Credential | DDS
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Telephone | 215-527-8768
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | 054360
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License Number State | NY
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