1184921520 NPI number — ILLUSTRADENT WESTCHESTER DENTAL SERVICES, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184921520 NPI number — ILLUSTRADENT WESTCHESTER DENTAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLUSTRADENT WESTCHESTER DENTAL SERVICES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CROSS COUNTY DENTAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184921520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 CENTRAL PARK AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
YONKERS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10710-4905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-779-4858
Provider Business Mailing Address Fax Number:
914-395-0101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 CENTRAL PARK AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
YONKERS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10710-4905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-779-4858
Provider Business Practice Location Address Fax Number:
914-395-0101
Provider Enumeration Date:
02/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENBERG
Authorized Official First Name:
MARA
Authorized Official Middle Name:
PAIGE
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
914-779-4858

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  052858 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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