1699076083 NPI number — URBAN PEDIATRIC DENTAL PC

Table of content: (NPI 1699076083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699076083 NPI number — URBAN PEDIATRIC DENTAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URBAN PEDIATRIC 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:
1699076083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 MOTT STREET
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10013-5575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 MOTT STREET
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10013-5575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-965-8113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MARN
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
LOO
Authorized Official Title or Position:
PRACTICE OWNER
Authorized Official Telephone Number:
212-965-8113

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  0497501 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 302R00000X , with the licence number: 0535941 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02902734 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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