MEDICARE: ELDRIDGE DENTAL CARE 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	0419971	NY
2	1223G0001X	General Practice Dentistry	050410	NY
3	1223G0001X	General Practice Dentistry	051388	NY
4	1223G0001X	General Practice Dentistry	047879	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	:	1194862953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELDRIDGE DENTAL CARE P.C.

Provider Business Mailing Address
First Line	:	1432 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2204
Country	:	US
Telephone Number	:	718-442-9254
Fax Number	:	718-720-9107

Provider Business Practice Location Address
First Line	:	1432 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2204
Country	:	US
Telephone Number	:	718-442-9254
Fax Number	:	718-720-9107

Authorized Official
Title or Position	:	CEO
Name	:	DR. DMITRIY VOLOTSENKO
Credential	:	DDS
Telephone Number	:	718-442-9254

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	08/22/2020

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Directions to “ELDRIDGE DENTAL CARE P.C. ” Practice Location

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