MEDICARE: LYDIG DENTAL

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	040647	NY

General Provider Information

NPI Number	:	1871735589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYDIG DENTAL

Provider Business Mailing Address
First Line	:	2120 MATTHEWS AVE
Second Line	:	1 FLOOR
City	:	BRONX
State	:	NY
Zip	:	10462-2637
Country	:	US
Telephone Number	:	718-863-4777
Fax Number	:	718-892-8884

Provider Business Practice Location Address
First Line	:	2120 MATTHEWS AVE
Second Line	:	1 FLOOR
City	:	BRONX
State	:	NY
Zip	:	10462-2637
Country	:	US
Telephone Number	:	718-863-4777
Fax Number	:	718-892-8884

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. YAKOV PILTSER
Credential	:	DDS.
Telephone Number	:	718-863-4777

Provider Enumeration Date	:	03/26/2009
Last Update Date	:	03/26/2009

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