MEDICARE: ST 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	122300000X	Dentist	045359-1	NY

General Provider Information

NPI Number	:	1326204397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST DENTAL

Provider Business Mailing Address
First Line	:	596 ANDERSON AVE
Second Line	:	SUITE 305
City	:	CLIFFSIDE PARK
State	:	NJ
Zip	:	07010-1831
Country	:	US
Telephone Number	:	973-479-3352
Fax Number	:

Provider Business Practice Location Address
First Line	:	1432 HYLAN BLVD
Second Line	:	2ND FLOOR
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-1923
Country	:	US
Telephone Number	:	973-479-3352
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	MS. LANA MARYASH
Credential	:
Telephone Number	:	973-479-3352

Provider Enumeration Date	:	07/30/2008
Last Update Date	:	07/30/2008

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Directions to “ST DENTAL ” Practice Location

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