=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508911769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL AVENUE DENTAL ARTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N CENTRAL AVE SUITE 280
-----------------------------------------------------
City | HARTSDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10530-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-997-2775
-----------------------------------------------------
Fax | 914-997-9394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N CENTRAL AVE SUITE 280
-----------------------------------------------------
City | HARTSDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10530-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-997-2775
-----------------------------------------------------
Fax | 914-997-9394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IRA LEVINE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 914-997-2775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 042878
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------