MEDICARE: ADVANCED DENTISTRY DENTAL OFFICE 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	122300000X	Dentist	0467811	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	:	1447478318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DENTISTRY DENTAL OFFICE PC

Provider Business Mailing Address
First Line	:	3051 OCEAN AVE
Second Line	:	SUITE A10
City	:	BROOKLYN
State	:	NY
Zip	:	11235
Country	:	US
Telephone Number	:	718-934-9494
Fax Number	:	718-891-6439

Provider Business Practice Location Address
First Line	:	3051 OCEAN AVE
Second Line	:	SUITE A10
City	:	BROOKLYN
State	:	NY
Zip	:	11235
Country	:	US
Telephone Number	:	718-934-9494
Fax Number	:	718-891-6439

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TAMARA LIKHOLETOVA
Credential	:	DDS
Telephone Number	:	718-934-9494

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	08/03/2010

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