=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730554049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RN DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2015
-----------------------------------------------------
Last Update Date | 12/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 BOND ST STE 203
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-978-0084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 BOND ST STE 203
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-978-0084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. RICHARD NEJAT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 917-287-1179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 047153
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------