Provider Demographics
NPI:1043632318
Name:ELITE DENTAL OF STATEN ISLAND,PC
Entity Type:Organization
Organization Name:ELITE DENTAL OF STATEN ISLAND,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-370-1200
Mailing Address - Street 1:2291 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6625
Mailing Address - Country:US
Mailing Address - Phone:718-370-1200
Mailing Address - Fax:718-370-1207
Practice Address - Street 1:2291 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6625
Practice Address - Country:US
Practice Address - Phone:718-370-1200
Practice Address - Fax:718-370-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036474122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7054750001Medicare NSC