MEDICARE: BROOKLYN PERIODONTICS AND IMPLANT DENTISTRY, 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	1223P0300X	Periodontics	052187	NY

General Provider Information

NPI Number	:	1093958282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKLYN PERIODONTICS AND IMPLANT DENTISTRY, P.C.

Provider Business Mailing Address
First Line	:	185 MONTAGUE ST
Second Line	:	9TH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3600
Country	:	US
Telephone Number	:	718-643-1953
Fax Number	:

Provider Business Practice Location Address
First Line	:	185 MONTAGUE ST
Second Line	:	9TH FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3600
Country	:	US
Telephone Number	:	718-643-1953
Fax Number	:

Authorized Official
Title or Position	:	PERIODONTIST
Name	:	DR. MICHAEL ZIDILE
Credential	:	D.D.S.
Telephone Number	:	718-643-1953

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	10/01/2013

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