MEDICARE: TRIBECA DENTAL CLINIQUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223P0300X	Periodontics
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1942452396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIBECA DENTAL CLINIQUE

Provider Business Mailing Address
First Line	:	123 CHAMBERS ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10007-1332
Country	:	US
Telephone Number	:	212-587-0000
Fax Number	:	212-587-0033

Provider Business Practice Location Address
First Line	:	123 CHAMBERS ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10007-1332
Country	:	US
Telephone Number	:	212-587-0000
Fax Number	:	212-587-0033

Authorized Official
Title or Position	:	DENTIST
Name	:	AZAR BOUJARAN-GHOMI
Credential	:
Telephone Number	:	212-587-0000

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	10/16/2008

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