MEDICARE: NORTHEAST DENTAL CENTER, 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	DS036113	PA

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	:	1992967475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST DENTAL CENTER, P.C.

Provider Business Mailing Address
First Line	:	10847 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3301
Country	:	US
Telephone Number	:	215-552-9800
Fax Number	:	215-552-9876

Provider Business Practice Location Address
First Line	:	10847 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3301
Country	:	US
Telephone Number	:	215-552-9800
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. OLEG AMAYEV
Credential	:
Telephone Number	:	215-552-9800

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	10/17/2011

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