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General NPI Number Information
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NPI Number | 1518297852
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Entity Type | Organization
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Legal Business Name | SERENE DENTAL LLC
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Dates
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Enumeration Date | 01/08/2010
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Last Update Date | 01/08/2010
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Provider Practice Location Address
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Address Line | 315 W 57TH ST SUITE 209
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City | NEW YORK
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State | NY
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Zip | 10019-3158
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Country | US
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Telephone | 917-338-6358
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Fax | 917-470-9486
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Provider Business Mailing Address
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Address Line | 801 W 181ST ST APT. 26
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City | NEW YORK
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State | NY
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Zip | 10033-4542
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Country | US
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Telephone | 917-881-5977
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Fax | 917-338-7771
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | ALTAY KHANMAMEDOV
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Credential | DDS
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Telephone | 917-881-5977
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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 | 051162
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License Number State | NY
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