1285741140 NPI number — RSN DENTAL PC

Table of content: (NPI 1285741140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285741140 NPI number — RSN DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RSN DENTAL 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:
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:
1285741140
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:
3589 RICHMOND AVE
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10312-3410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-317-1737
Provider Business Mailing Address Fax Number:
718-317-1739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3589 RICHMOND AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10312-3410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-317-1737
Provider Business Practice Location Address Fax Number:
718-317-1739
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHIKHMANTER
Authorized Official First Name:
VLADISLAV
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTITIONER/PRESIDENT
Authorized Official Telephone Number:
718-317-1737

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  048325 , 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: 01978954 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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