=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750657557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE DENTAL CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2012
-----------------------------------------------------
Last Update Date | 03/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1019 PARK ST SUITE 201
-----------------------------------------------------
City | PEEKSKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10566-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-737-1911
-----------------------------------------------------
Fax | 914-737-1943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1019 PARK ST SUITE 201
-----------------------------------------------------
City | PEEKSKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10566-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-737-1911
-----------------------------------------------------
Fax | 914-737-1943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSHUA D ILAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 914-737-1911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 051103
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------