=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487038568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G&A FAMILY DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2015
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 FOXHURST RD
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-766-2595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 BROOKLAWN AVE
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06604-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-334-4837
-----------------------------------------------------
Fax | 203-366-9195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK AGABABAEV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 203-334-4837
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 010091
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------