=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760727754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D&L DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2012
-----------------------------------------------------
Last Update Date | 12/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92-11 35AVE APT 1K
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-901-3821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21120 69TH AVE
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11364-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-901-3821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELINA KAS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 347-901-3821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 052922
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------