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General NPI Number Information
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NPI Number | 1770295255
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Entity Type | Organization
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Legal Business Name | STATEN ISLAND DENTAL BOUTIQUE
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Dates
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Enumeration Date | 12/16/2022
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Last Update Date | 12/16/2022
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Provider Practice Location Address
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Address Line | 1735 RICHMOND AVE FL 2
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3907
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Country | US
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Telephone | 347-596-7719
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Fax |
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Provider Business Mailing Address
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Address Line | 81 NARROWS RD N APT D
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City | STATEN ISLAND
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State | NY
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Zip | 10305-2818
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Country | US
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Telephone | 347-596-7719
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. OLENA RONAN
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Credential | DDS
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Telephone | 347-596-7719
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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