MEDICARE: BOUTIQUE 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	055256	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	:	1285079962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOUTIQUE DENTAL

Provider Business Mailing Address
First Line	:	6835 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7234
Country	:	US
Telephone Number	:	718-821-0170
Fax Number	:

Provider Business Practice Location Address
First Line	:	6835 MYRTLE AVE
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7234
Country	:	US
Telephone Number	:	718-821-0170
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. YELENA M MULLAKANDOVA
Credential	:	DDS
Telephone Number	:	917-640-1100

Provider Enumeration Date	:	05/07/2013
Last Update Date	:	07/19/2014

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Directions to “BOUTIQUE DENTAL ” Practice Location

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