=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487350864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DV DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2023
-----------------------------------------------------
Last Update Date | 02/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 AVENUE A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-259-0595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2410 NATIONAL DR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-6836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-797-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DMITRIY VOLOTSENKO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-797-8052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------