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General NPI Number Information
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NPI Number | 1760763148
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Entity Type | Organization
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Legal Business Name | GALLERY 57 DENTAL
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 08/30/2011
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Provider Practice Location Address
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Address Line | 24 W 57TH ST SUITE 701
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City | NEW YORK
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State | NY
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Zip | 10019-3918
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Country | US
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Telephone | 212-246-8700
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Fax | 212-246-8707
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Provider Business Mailing Address
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Address Line | 24 W 57TH ST SUITE 701
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City | NEW YORK
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State | NY
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Zip | 10019-3918
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Country | US
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Telephone | 212-246-8700
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Fax | 212-246-8707
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | MASON KOSTINSKY
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Credential |
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Telephone | 212-246-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 033746
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 035303
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License Number State | NY
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