MEDICARE: BP DENTISTRY FOR KIDS 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	261QD0000X	Dental Clinic/Center	057524	NY
2	261QD0000X	Dental Clinic/Center	057648	NY

General Provider Information

NPI Number	:	1861944043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BP DENTISTRY FOR KIDS PC

Provider Business Mailing Address
First Line	:	5309 18TH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1523
Country	:	US
Telephone Number	:	718-644-0287
Fax Number	:

Provider Business Practice Location Address
First Line	:	5309 18TH AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1523
Country	:	US
Telephone Number	:	718-644-0287
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. ELLIOT LUTZ
Credential	:	DDS
Telephone Number	:	347-244-2914

Provider Enumeration Date	:	11/03/2016
Last Update Date	:	11/03/2016

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