MEDICARE: CHURCH AVENUE 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	1223G0001X	General Practice Dentistry	049110-1	NY

General Provider Information

NPI Number	:	1134118219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHURCH AVENUE DENTAL P.C.

Provider Business Mailing Address
First Line	:	1113 CHURCH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11218-2803
Country	:	US
Telephone Number	:	718-941-7275
Fax Number	:	718-532-0917

Provider Business Practice Location Address
First Line	:	1113 CHURCH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11218-2803
Country	:	US
Telephone Number	:	718-941-7275
Fax Number	:	718-532-0917

Authorized Official
Title or Position	:	DDS
Name	:	STEVE TARANOV
Credential	:	DDS
Telephone Number	:	718-941-7275

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	08/22/2020

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