MEDICARE: EAST SIDE PEDIATRIC DENTAL

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1538539986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE PEDIATRIC DENTAL

Provider Business Mailing Address
First Line	:	128 MOTT STREET
Second Line	:	SUITE 403
City	:	NEW YORK
State	:	NY
Zip	:	10013-5575
Country	:	US
Telephone Number	:	212-965-8113
Fax Number	:	212-965-8114

Provider Business Practice Location Address
First Line	:	133 EAST 58TH STREET
Second Line	:	SUITE 402
City	:	NEW YORK
State	:	NY
Zip	:	10022-1157
Country	:	US
Telephone Number	:	212-965-8113
Fax Number	:	212-965-8114

Authorized Official
Title or Position	:	PEDIATRIC DENTIST/PRESIDENT
Name	:	DR. JESSICA LOO MARN
Credential	:	DDS
Telephone Number	:	212-965-8113

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/29/2015

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