Provider Demographics
NPI:1003391186
Name:2791 RICHMOND LLC
Entity Type:Organization
Organization Name:2791 RICHMOND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:TONI LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-979-2121
Mailing Address - Street 1:2791 RICHMOND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5859
Mailing Address - Country:US
Mailing Address - Phone:718-400-9002
Mailing Address - Fax:
Practice Address - Street 1:2791 RICHMOND AVENUE, SUITE 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-400-9002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty