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General NPI Number Information
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NPI Number | 1629490826
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Entity Type | Organization
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Legal Business Name | FORMOSO DENTAL PC
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Dates
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Enumeration Date | 01/08/2014
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 30 E 40TH ST RM 305
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City | NEW YORK
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State | NY
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Zip | 10016-1247
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Country | US
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Telephone | 212-370-1919
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Fax |
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Provider Business Mailing Address
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Address Line | 202 UNION AVE D
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City | BROOKLYN
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State | NY
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Zip | 11211-1739
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Country | US
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Telephone | 718-388-4613
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID FORMOSAN LEE
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Credential | DDS
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Telephone | 718-388-4613
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 053083
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License Number State | NY
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