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General NPI Number Information
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NPI Number | 1528402112
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Entity Type | Organization
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Legal Business Name | ELMHURST ORTHODONTICS, PC
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Dates
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Enumeration Date | 04/25/2013
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Last Update Date | 04/25/2013
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Provider Practice Location Address
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Address Line | 79-11 41ST AVE UNIT A107
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City | ELMHURST
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State | NY
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Zip | 11373-1258
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Country | US
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Telephone | 718-205-2888
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Fax |
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Provider Business Mailing Address
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Address Line | 79-11 41ST AVE UNIT A107
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City | ELMHURST
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State | NY
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Zip | 11373-1258
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Country | US
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Telephone | 718-205-2888
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. ARIEL BALES-KOGAN
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Credential | DMD, MSD, CAGS
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Telephone | 617-319-4180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 055373
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License Number State | NY
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