MEDICARE: CITIBRITES DENTAL LLC

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	040944	NY

General Provider Information

NPI Number	:	1760917918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITIBRITES DENTAL LLC

Provider Business Mailing Address
First Line	:	131 ARNOLD ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-2236
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 ARNOLD ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-2236
Country	:	US
Telephone Number	:	718-714-8747
Fax Number	:

Authorized Official
Title or Position	:	NON MEMBER MANAGER
Name	:	MR. JOSHUA SANDERS
Credential	:
Telephone Number	:	201-304-4137

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	04/25/2017

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