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General NPI Number Information
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NPI Number | 1992127765
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Entity Type | Organization
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Legal Business Name | 125TH STREET ORTHODONTICS, PC
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Dates
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Enumeration Date | 01/14/2014
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Last Update Date | 01/14/2014
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Provider Practice Location Address
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Address Line | 360 W 125TH ST SUITE 8
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City | NEW YORK
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State | NY
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Zip | 10027-4801
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Country | US
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Telephone | 646-221-8944
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Fax |
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Provider Business Mailing Address
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Address Line | 789 W END AVE APT.. 12-A
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City | NEW YORK
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State | NY
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Zip | 10025-5469
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Country | US
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Telephone | 646-221-8944
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Fax | 212-233-8348
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Authorized Official
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Title or Position | SECRETARY
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Name | DR. KENNETH BRUCE COOPERMAN
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Credential | DMD
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Telephone | 646-221-8944
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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 | 046957
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License Number State | NY
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