1134118219 NPI number — CHURCH AVENUE DENTAL 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 1134118219 NPI number — CHURCH AVENUE DENTAL P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHURCH AVENUE DENTAL 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:
1134118219
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:
1113 CHURCH AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11218-2803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-941-7275
Provider Business Mailing Address Fax Number:
718-532-0917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1113 CHURCH AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11218-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-941-7275
Provider Business Practice Location Address Fax Number:
718-532-0917
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TARANOV
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
DDS
Authorized Official Telephone Number:
718-941-7275

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  049110-1 , 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)





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