=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932453172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P&R EXECUTIVE DENTAL MANAGEMENT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2012
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-426-8202
-----------------------------------------------------
Fax | 212-426-6802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2127 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-426-8202
-----------------------------------------------------
Fax | 212-426-6802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. VERONICA DIAZ
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 212-426-8202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0550851
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------