MEDICARE: NANUET MALL DENTAL, P.C.

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	049059	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	:	1609093905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NANUET MALL DENTAL, P.C.

Provider Business Mailing Address
First Line	:	75 W ROUTE 59
Second Line	:	SUITE# 1009A
City	:	NANUET
State	:	NY
Zip	:	10954-2700
Country	:	US
Telephone Number	:	845-624-7500
Fax Number	:	845-624-7505

Provider Business Practice Location Address
First Line	:	75 W ROUTE 59
Second Line	:	SUITE# 1009A
City	:	NANUET
State	:	NY
Zip	:	10954-2700
Country	:	US
Telephone Number	:	845-624-7500
Fax Number	:	845-624-7505

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. YELENA KHRAPKO
Credential	:	DDS
Telephone Number	:	845-624-7500

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	08/22/2020

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Directions to “NANUET MALL DENTAL, P.C. ” Practice Location

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