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General NPI Number Information
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NPI Number | 1699076083
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Entity Type | Organization
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Legal Business Name | URBAN PEDIATRIC DENTAL PC
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Dates
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Enumeration Date | 11/16/2010
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Last Update Date | 01/24/2013
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Provider Practice Location Address
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Address Line | 128 MOTT STREET SUITE 203
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City | NEW YORK
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State | NY
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Zip | 10013-5575
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Country | US
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Telephone | 212-965-8113
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Fax |
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Provider Business Mailing Address
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Address Line | 128 MOTT STREET SUITE 203
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City | NEW YORK
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State | NY
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Zip | 10013-5575
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE OWNER
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Name | MS. JESSICA LOO MARN
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Credential | D.D.S
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Telephone | 212-965-8113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 0535941
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 0497501
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License Number State | NY
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