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General NPI Number Information
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NPI Number | 1871981068
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Entity Type | Organization
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Legal Business Name | CREATIVE DENTAL OF QUEENS
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Dates
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Enumeration Date | 12/23/2014
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Last Update Date | 12/23/2014
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Provider Practice Location Address
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Address Line | 63-58 WETHEROLE STREET
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City | REGO PARK
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State | NY
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Zip | 11374
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Country | US
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Telephone | 718-459-4700
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Fax | 914-390-9111
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Provider Business Mailing Address
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Address Line | 63-58 WETHEROLE STREET
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City | REGO PARK
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State | NY
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Zip | 11374
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Country | US
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Telephone | 718-459-4700
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Fax | 914-390-9111
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Authorized Official
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Title or Position | DENTIST
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Name | TIMUR MOZNER
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Credential | D.D.S.
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Telephone | 718-459-4700
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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 | 048393
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License Number State | NY
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