1760452106 NPI number — JACKSON HEIGHTS DENTAL MR, PC

Table of content: (NPI 1760452106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760452106 NPI number — JACKSON HEIGHTS DENTAL MR, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HEIGHTS DENTAL MR, 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:
JACKSON HEIGHTS DENTAL CENTER
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:
1760452106
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8509 37TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON HEIGHTS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11372-7344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-651-4523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8509 37TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-7344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-651-4523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LORBER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-651-4523

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  047347 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 122300000X , with the licence number: 046409 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223G0001X , with the licence number: 052071 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0300X , with the licence number: 047303 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 01912481 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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