MEDICARE: PROHEALTH RIVERSIDE DENTAL, LLC

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	:	1073151114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROHEALTH RIVERSIDE DENTAL, LLC

Provider Business Mailing Address
First Line	:	1 PRO HEALTH PLZ STE 300
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042
Country	:	US
Telephone Number	:	516-654-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 RIVER RD STE 104
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1002
Country	:	US
Telephone Number	:	201-941-0088
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	NEIL KARNOFSKY
Credential	:	DDS
Telephone Number	:	516-654-4400

Provider Enumeration Date	:	12/19/2019
Last Update Date	:	12/19/2019

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