1699922088 NPI number — HOLLIS ADVANCED DENTAL CARE P.C.

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 1699922088 NPI number — HOLLIS ADVANCED DENTAL CARE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLIS ADVANCED DENTAL CARE P.C.
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:
1699922088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19002 JAMAICA AVE
Provider Second Line Business Mailing Address:
2 FLOOR
Provider Business Mailing Address City Name:
HOLLIS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11423-2516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-454-7418
Provider Business Mailing Address Fax Number:
718-217-2657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19002 JAMAICA AVE
Provider Second Line Business Practice Location Address:
2 FLOOR
Provider Business Practice Location Address City Name:
HOLLIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11423-2516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-454-7418
Provider Business Practice Location Address Fax Number:
718-217-2657
Provider Enumeration Date:
08/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KATAYEV
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-454-7418

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0300X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , 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)

  • Identifier: 011896900 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02587795 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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