MEDICARE: FIFTH AVENUE DENTAL 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	122300000X	Dentist	033327	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	:	1710999438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIFTH AVENUE DENTAL PC

Provider Business Mailing Address
First Line	:	4607 5TH AVE # 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-1207
Country	:	US
Telephone Number	:	718-854-3191
Fax Number	:	718-272-4688

Provider Business Practice Location Address
First Line	:	4607 5TH AVE # 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-1207
Country	:	US
Telephone Number	:	718-854-3191
Fax Number	:	718-272-4688

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. VIRENDRA SHAH
Credential	:	DDS
Telephone Number	:	718-854-3191

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	08/22/2020

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1275740656 — DR. JOSEFINA S. VELASQUEZ M.D.
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1366985491 — JESAL SHAH, DMD, P.C.
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