MEDICARE: ATLANTIC AVENUE ORTHODONTICS, 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	051019	NY

General Provider Information

NPI Number	:	1790266187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC AVENUE ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	315 W 70TH ST APT 1J
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-3529
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 ATLANTIC AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-2407
Country	:	US
Telephone Number	:	646-505-8852
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL KUNCIO
Credential	:	DDS
Telephone Number	:	646-505-8852

Provider Enumeration Date	:	08/24/2018
Last Update Date	:	08/24/2018

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