=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801211370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISON AVENUE DENTISTRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2014
-----------------------------------------------------
Last Update Date | 02/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 MADISON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-532-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MADISON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-532-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. LAURENCE E FENDRICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-532-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 035301
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------