Provider Demographics
NPI:1043565575
Name:QUEENS ORTHODONTICS
Entity Type:Organization
Organization Name:QUEENS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-400-3822
Mailing Address - Street 1:3097 STEINWAY ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3440
Mailing Address - Country:US
Mailing Address - Phone:718-545-5100
Mailing Address - Fax:
Practice Address - Street 1:3097 STEINWAY ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3440
Practice Address - Country:US
Practice Address - Phone:718-545-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
047218-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty