=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689171043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN PEIKARIAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2018
-----------------------------------------------------
Last Update Date | 08/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11316 76TH RD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-575-9548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 199 W SHORE RD
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11024-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 060491
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------