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General NPI Number Information
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NPI Number | 1932326618
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Entity Type | Organization
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Legal Business Name | GALLERIA MALL DENTAL PC
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1 N GALLERIA DR STE 141
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City | MIDDLETOWN
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State | NY
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Zip | 10941-3030
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Country | US
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Telephone | 845-692-9212
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Fax | 845-692-9215
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Provider Business Mailing Address
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Address Line | 1 N GALLERIA DR STE 141
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City | MIDDLETOWN
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State | NY
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Zip | 10941-3030
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Country | US
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Telephone | 845-692-9212
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Fax | 845-692-9215
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | ROSS KRASNOV
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Credential |
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Telephone | 845-692-9212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 049213
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 052828
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 048760
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License Number State | NY
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Taxonomy #4
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 042707
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License Number State | NY
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