Provider Demographics
NPI:1043580038
Name:RADIANT SMILE DENTAL CARE PC
Entity Type:Organization
Organization Name:RADIANT SMILE DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASTEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-355-9510
Mailing Address - Street 1:812 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4514
Mailing Address - Country:US
Mailing Address - Phone:516-355-9510
Mailing Address - Fax:516-437-4567
Practice Address - Street 1:812 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4514
Practice Address - Country:US
Practice Address - Phone:516-355-9510
Practice Address - Fax:516-437-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044978261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental