MEDICARE: EDOUARD ETLIS DENTAL, P.C.

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	047627	NY

General Provider Information

NPI Number	:	1952765828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDOUARD ETLIS DENTAL, P.C.

Provider Business Mailing Address
First Line	:	80 FOCH AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-4438
Country	:	US
Telephone Number	:
Fax Number	:	718-495-8803

Provider Business Practice Location Address
First Line	:	9516 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-2434
Country	:	US
Telephone Number	:	718-495-8801
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDOUARD ETLIS
Credential	:	DDS
Telephone Number	:	646-512-2777

Provider Enumeration Date	:	04/07/2016
Last Update Date	:	04/07/2016

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