1306050869 NPI number — FORDHAM ROAD DENTAL PC

Table of content: (NPI 1306050869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306050869 NPI number — FORDHAM ROAD DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORDHAM ROAD DENTAL PC
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:
EXECUTIVE ASSOCIATES, LLC
Provider Other Organization Name Type Code:
4
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:
1306050869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 E FORDHAM RD
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10458-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-933-8400
Provider Business Mailing Address Fax Number:
718-933-3731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 E FORDHAM RD
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10458-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-933-8400
Provider Business Practice Location Address Fax Number:
718-933-3731
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERTUZZI
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
845-304-6110

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com