MEDICARE: SP DENTAL, 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	1223G0001X	General Practice Dentistry	049663	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932370970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SP DENTAL, PC

Provider Business Mailing Address
First Line	:	3627 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-2518
Country	:	US
Telephone Number	:	212-234-2300
Fax Number	:	212-234-2301

Provider Business Practice Location Address
First Line	:	3627 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-2518
Country	:	US
Telephone Number	:	212-234-2300
Fax Number	:	212-234-2301

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	SVETLANA PONOMAREVA
Credential	:	DDS
Telephone Number	:	212-234-2300

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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