MEDICARE: RUBEN'S 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	1223G0001X	General Practice Dentistry	046847	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	:	1720250558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUBEN'S DENTAL, PLLC

Provider Business Mailing Address
First Line	:	10510 62ND RD APT 1F
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1122
Country	:	US
Telephone Number	:	718-760-8400
Fax Number	:	718-760-8114

Provider Business Practice Location Address
First Line	:	10510 62ND RD APT 1F
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1122
Country	:	US
Telephone Number	:	718-760-8400
Fax Number	:	718-760-8114

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RUBEN FATTAKHOV
Credential	:	DDS
Telephone Number	:	718-760-8400

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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