=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730338369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIA UNIV DENTAL SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2008
-----------------------------------------------------
Last Update Date | 09/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 W 168TH ST VANDERBILT CLINIC 9TH FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-305-5686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 W 168TH ST P&S BOX 30
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-305-5686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DEAN FOR CLINICAL AFFAIRS
-----------------------------------------------------
Name | DR. RONNIE MYERS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 212-305-5686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------