Provider First Line Business Practice Location Address: 
585 SCHENCTADY AVE
    Provider Second Line Business Practice Location Address: 
KINGSBROOK JEWISH MEDICAL CENTER, DENTAL DEPT
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11203
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-604-5381
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/27/2019