1114398807 NPI number — JACOB A. AVNER, DDS PC

Table of content: (NPI 1114398807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114398807 NPI number — JACOB A. AVNER, DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACOB A. AVNER, DDS 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:
Provider Other Organization Name Type Code:
6
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:
1114398807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9725 64TH AVE
Provider Second Line Business Mailing Address:
UNIT: G-3
Provider Business Mailing Address City Name:
REGO PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11374-2236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-275-7300
Provider Business Mailing Address Fax Number:
718-275-7307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9725 64TH AVE
Provider Second Line Business Practice Location Address:
UNIT: G-3
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-275-7300
Provider Business Practice Location Address Fax Number:
718-275-7307
Provider Enumeration Date:
10/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
AVNER
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
718-275-7300

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  0496891 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02282222 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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