1649318601 NPI number — SAND LANE DENTAL PC

Table of content: (NPI 1649318601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649318601 NPI number — SAND LANE DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAND LANE 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:
1649318601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 CLAWSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10306-3222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-273-5006
Provider Business Mailing Address Fax Number:
718-273-2778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 SAND LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10305-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-273-5006
Provider Business Practice Location Address Fax Number:
718-273-2778
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TKACHUK
Authorized Official First Name:
ANDZHELA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
718-273-5006

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  050679 , 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: 02408771 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02410680 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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