MEDICARE: NORTHERN CITY DENTAL, P.C.

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	0441781	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	:	1366770232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN CITY DENTAL, P.C.

Provider Business Mailing Address
First Line	:	714 BEACH 20TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3502
Country	:	US
Telephone Number	:	917-476-6161
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 BEACH 20TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3502
Country	:	US
Telephone Number	:	917-476-6161
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANNA RABICHEV
Credential	:	DDS
Telephone Number	:	917-476-6161

Provider Enumeration Date	:	12/03/2009
Last Update Date	:	12/03/2009

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