Provider Demographics
NPI:1003087008
Name:DR. MIRYEM KANDINOV D.D.S PC
Entity Type:Organization
Organization Name:DR. MIRYEM KANDINOV D.D.S PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRYEM
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDINOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-261-6310
Mailing Address - Street 1:123-60 83 AVE
Mailing Address - Street 2:SUITE 2W
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415
Mailing Address - Country:US
Mailing Address - Phone:718-261-6310
Mailing Address - Fax:718-261-1085
Practice Address - Street 1:123-60 83 AVE
Practice Address - Street 2:SUITE 2W
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415
Practice Address - Country:US
Practice Address - Phone:718-261-6310
Practice Address - Fax:718-261-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0450111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01474033Medicaid