MEDICARE: EAST HARLEM DENTAL PLAZE, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1477606648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST HARLEM DENTAL PLAZE, PC

Provider Business Mailing Address
First Line	:	2060 LEXINGTON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1732
Country	:	US
Telephone Number	:	212-996-5996
Fax Number	:	212-669-0030

Provider Business Practice Location Address
First Line	:	2060 LEXINGTON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1732
Country	:	US
Telephone Number	:	212-996-5996
Fax Number	:	212-669-0030

Authorized Official
Title or Position	:	OWNER
Name	:	DR. VERA HEIFETZ-KHRAKOVSKY
Credential	:
Telephone Number	:	212-996-5996

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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