1902199870 NPI number — QUEENS FAMILY DENTAL LIC

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 1902199870 NPI number — QUEENS FAMILY DENTAL LIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEENS FAMILY DENTAL LIC
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:
1902199870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2602 DITMARS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASTORIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11105-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-278-5700
Provider Business Mailing Address Fax Number:
718-278-5794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2602 DITMARS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11105-3123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-278-5700
Provider Business Practice Location Address Fax Number:
718-278-5794
Provider Enumeration Date:
05/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ELIADES
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-278-5700

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  037540 , 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: 00851547 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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