Provider Demographics
NPI:1033571203
Name:DISCOUNT DENTAL
Entity Type:Organization
Organization Name:DISCOUNT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MMSC
Authorized Official - Phone:718-460-6868
Mailing Address - Street 1:14210 ROOSEVELT AVE # 8
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6046
Mailing Address - Country:US
Mailing Address - Phone:718-460-6868
Mailing Address - Fax:718-460-2112
Practice Address - Street 1:14210 ROOSEVELT AVE # 8
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6046
Practice Address - Country:US
Practice Address - Phone:718-460-6868
Practice Address - Fax:718-460-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057991122300000X
NY057616122300000X
NY0482111223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02455109Medicaid