Provider Demographics
NPI:1003958398
Name:AAA UPTOWN STAR DENTAL PC
Entity Type:Organization
Organization Name:AAA UPTOWN STAR DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALENTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRIVOSHEYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-569-4652
Mailing Address - Street 1:680 W 204TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3003
Mailing Address - Country:US
Mailing Address - Phone:212-569-4652
Mailing Address - Fax:212-569-4644
Practice Address - Street 1:680 W 204TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3003
Practice Address - Country:US
Practice Address - Phone:212-569-4652
Practice Address - Fax:212-569-4644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0461051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995757Medicaid