1467574871 NPI number — IDEAL DENTAL CARE

Table of content: (NPI 1467574871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467574871 NPI number — IDEAL DENTAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL DENTAL CARE
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:
Provider Other Organization Name Type Code:
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:
1467574871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 NORTHERN BOULEVARD
Provider Second Line Business Mailing Address:
SUITE #6
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-487-6453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 NORTHERN BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE #6
Provider Business Practice Location Address City Name:
GREAT NECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-487-6453
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GLAVAS
Authorized Official First Name:
PANAGIOTIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-487-6453

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  047563 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 047563 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X , with the licence number: 047563 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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