MEDICARE: CITY ISLAND DENTAL, PC

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

General Provider Information

NPI Number	:	1265175558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY ISLAND DENTAL, PC

Provider Business Mailing Address
First Line	:	1040 1ST AVE # 393
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-2991
Country	:	US
Telephone Number	:	917-583-5457
Fax Number	:	718-480-6374

Provider Business Practice Location Address
First Line	:	163 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1537
Country	:	US
Telephone Number	:	718-885-1688
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	JOHANNY RODRIGUEZ
Credential	:
Telephone Number	:	917-583-5457

Provider Enumeration Date	:	04/15/2022
Last Update Date	:	04/15/2022

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