MEDICARE: DR. TAJUL ISLAM DDS 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	261QD0000X	Dental Clinic/Center	050581	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9179252	OTHER		DORAL DENTAL IPA OF NEW Y
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558569582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. TAJUL ISLAM DDS PC

Provider Business Mailing Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-622-1868
Fax Number	:

Provider Business Practice Location Address
First Line	:	1236 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2093
Country	:	US
Telephone Number	:	718-622-1868
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TAJUL ISLAM
Credential	:	D.D.S.
Telephone Number	:	718-622-1868

Provider Enumeration Date	:	07/11/2007
Last Update Date	:	07/11/2007

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