MEDICARE: MONTEFIORE DENTAL DEPARTMENT

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

General Provider Information

NPI Number	:	1023213337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTEFIORE DENTAL DEPARTMENT

Provider Business Mailing Address
First Line	:	PO BOX 4156
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10261-4156
Country	:	US
Telephone Number	:	718-920-4168
Fax Number	:	718-515-5419

Provider Business Practice Location Address
First Line	:	1516 JARRET PL
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-2607
Country	:	US
Telephone Number	:	888-700-6623
Fax Number	:	718-515-5419

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CHARLES BROCKETT
Credential	:
Telephone Number	:	718-920-4167

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	08/22/2020

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Directions to “MONTEFIORE DENTAL DEPARTMENT ” Practice Location

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