=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538501267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAMERCY PARK DENTAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2013
-----------------------------------------------------
Last Update Date | 07/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 3RD AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-889-0999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 3RD AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-889-0999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL DIRECTOR
-----------------------------------------------------
Name | DR. GLEN HOLLOWAY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 212-889-0999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 042637
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------