MEDICARE: MILLENNIUM SMILE DENTISTRY, 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	261QD0000X	Dental Clinic/Center	048425	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	:	1306931514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM SMILE DENTISTRY, PC

Provider Business Mailing Address
First Line	:	120 CABRINI BLVD
Second Line	:	#10
City	:	NEW YORK
State	:	NY
Zip	:	10033-3438
Country	:	US
Telephone Number	:	212-740-7568
Fax Number	:	212-740-7568

Provider Business Practice Location Address
First Line	:	120 CABRINI BLVD
Second Line	:	#10
City	:	NEW YORK
State	:	NY
Zip	:	10033-3438
Country	:	US
Telephone Number	:	212-740-7568
Fax Number	:	212-740-7568

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VITALIY FABRIKANT
Credential	:	DMD
Telephone Number	:	212-740-7568

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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