MEDICARE: 174 STREET 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	1223G0001X	General Practice Dentistry	053429	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134358427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	174 STREET DENTAL LLC

Provider Business Mailing Address
First Line	:	146 E 174TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10457-6904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	146 E 174TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10457-6904
Country	:	US
Telephone Number	:	213-709-7154
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JUSTIN SYCAMORE
Credential	:	DDS
Telephone Number	:	213-709-7154

Provider Enumeration Date	:	07/08/2009
Last Update Date	:	07/08/2009

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