1760452106 NPI number — JACKSON HEIGHTS DENTAL MR, PC

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 1760452106 NPI number — JACKSON HEIGHTS DENTAL MR, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON HEIGHTS DENTAL MR, 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:
JACKSON HEIGHTS DENTAL CENTER
Provider Other Organization Name Type Code:
3
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:
1760452106
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:
8509 37TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON HEIGHTS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11372-7344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-651-4523
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8509 37TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-7344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-651-4523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LORBER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-651-4523

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  047347 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 122300000X , with the licence number: 046409 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223G0001X , with the licence number: 052071 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0300X , with the licence number: 047303 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 01912481 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com