MEDICARE: OCEAN-SIDE 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	049909-1	NY

General Provider Information

NPI Number	:	1104352012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN-SIDE DENTAL P.C.

Provider Business Mailing Address
First Line	:	3260 CONEY ISLAND AVE
Second Line	:	UNIT A4
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6643
Country	:	US
Telephone Number	:	718-891-0021
Fax Number	:	718-891-4946

Provider Business Practice Location Address
First Line	:	3260 CONEY ISLAND AVE
Second Line	:	UNIT A4
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6643
Country	:	US
Telephone Number	:	718-891-0021
Fax Number	:	718-891-4946

Authorized Official
Title or Position	:	PRISIDENT
Name	:	IRINA GONCHARUK
Credential	:	DDS
Telephone Number	:	718-908-0464

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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