MEDICARE: 5TH AVENUE DENTAL ASSOC LLP

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist

General Provider Information

NPI Number	:	1184742298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH AVENUE DENTAL ASSOC LLP

Provider Business Mailing Address
First Line	:	7815 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3703
Country	:	US
Telephone Number	:	718-745-4422
Fax Number	:	718-745-8558

Provider Business Practice Location Address
First Line	:	7815 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3703
Country	:	US
Telephone Number	:	718-745-4422
Fax Number	:	718-745-8558

Authorized Official
Title or Position	:	OWNER
Name	:	GEORGE DIACOUMAKOS
Credential	:
Telephone Number	:	718-745-4422

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	09/08/2020

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