=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982992780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NN'S DENTAL GALLERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2011
-----------------------------------------------------
Last Update Date | 07/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 7TH AVE #800
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10123-0101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-695-2173
-----------------------------------------------------
Fax | 212-695-1921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 7TH AVE #800
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10123-0101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-695-2173
-----------------------------------------------------
Fax | 212-695-1921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NATALI GOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-695-2173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 050360
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------