MEDICARE: STATEN ISLAND MALL DENTAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	046-043	NY

General Provider Information

NPI Number	:	1013139237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN ISLAND MALL DENTAL, P.C.

Provider Business Mailing Address
First Line	:	2655 RICHMOND AVENUE
Second Line	:	2220
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314
Country	:	US
Telephone Number	:	718-982-5500
Fax Number	:	718-982-5554

Provider Business Practice Location Address
First Line	:	2655 RICHMOND AVENUE
Second Line	:	2220
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314
Country	:	US
Telephone Number	:	718-982-5500
Fax Number	:	718-982-5554

Authorized Official
Title or Position	:	DENTIST
Name	:	ROSS KRASNOV
Credential	:	D.D.S.
Telephone Number	:	718-982-5500

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/22/2020

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