MEDICARE: WINSTON DENTAL, LLC

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	1223G0001X	General Practice Dentistry		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	:	1356714968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINSTON DENTAL, LLC

Provider Business Mailing Address
First Line	:	300 E 40TH ST
Second Line	:	SUITE B
City	:	NEW YORK
State	:	NY
Zip	:	10016-2188
Country	:	US
Telephone Number	:	212-905-0081
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 E 40TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-2188
Country	:	US
Telephone Number	:	212-905-0081
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL I KATAYEV
Credential	:	DDS
Telephone Number	:	212-905-0081

Provider Enumeration Date	:	11/04/2015
Last Update Date	:	11/05/2015

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