MEDICARE: SUPERIOR DENTAL

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	261QD0000X	Dental Clinic/Center	049663	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	:	1275771248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR DENTAL

Provider Business Mailing Address
First Line	:	2475 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5443
Country	:	US
Telephone Number	:	718-329-2929
Fax Number	:	718-329-2930

Provider Business Practice Location Address
First Line	:	2475 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5443
Country	:	US
Telephone Number	:	718-329-2929
Fax Number	:	718-329-2930

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SVETLANA PONOMAREVA
Credential	:	DDS
Telephone Number	:	718-329-2929

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	01/29/2009

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Directions to “SUPERIOR DENTAL ” Practice Location

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