MEDICARE: RESTORATION 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	047164	NY

General Provider Information

NPI Number	:	1740261130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATION DENTAL, PLLC

Provider Business Mailing Address
First Line	:	289 JEFFERSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-1703
Country	:	US
Telephone Number	:	718-636-4700
Fax Number	:	718-636-4791

Provider Business Practice Location Address
First Line	:	289 JEFFERSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-1703
Country	:	US
Telephone Number	:	718-636-4700
Fax Number	:	718-636-4791

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	DR. ROBERT P LANE
Credential	:	DDS
Telephone Number	:	718-636-4700

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	06/17/2008

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