MEDICARE: UPPER DITMARS DENTAL PLLC

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	052126	NY

General Provider Information

NPI Number	:	1437695764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPPER DITMARS DENTAL PLLC

Provider Business Mailing Address
First Line	:	2128 80TH ST
Second Line	:
City	:	EAST ELMHURST
State	:	NY
Zip	:	11370-1323
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 80TH ST
Second Line	:
City	:	EAST ELMHURST
State	:	NY
Zip	:	11370-1323
Country	:	US
Telephone Number	:	908-705-7122
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ARISTOTLE LYSSIKATOS
Credential	:	DDS
Telephone Number	:	908-705-7122

Provider Enumeration Date	:	01/10/2017
Last Update Date	:	01/10/2017

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