MEDICARE: MADISON HAPPY SMILES DENTAL PLLC

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

General Provider Information

NPI Number	:	1619811346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON HAPPY SMILES DENTAL PLLC

Provider Business Mailing Address
First Line	:	9936 62ND DR
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-1938
Country	:	US
Telephone Number	:	917-565-6883
Fax Number	:	917-565-6883

Provider Business Practice Location Address
First Line	:	20 E 35TH ST
Second Line	:	2A DENTAL
City	:	NEW YORK
State	:	NY
Zip	:	10016-3887
Country	:	US
Telephone Number	:	917-565-6883
Fax Number	:	917-565-6883

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT FATAKHOV
Credential	:	DDS
Telephone Number	:	917-565-6883

Provider Enumeration Date	:	04/15/2026
Last Update Date	:	04/15/2026

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