Provider Demographics
NPI:1053689463
Name:GRAND DENTAL CARE PC
Entity Type:Organization
Organization Name:GRAND DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:CHAVEZ-ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-378-1968
Mailing Address - Street 1:2000 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2811
Mailing Address - Country:US
Mailing Address - Phone:516-378-1968
Mailing Address - Fax:516-608-9319
Practice Address - Street 1:2000 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2811
Practice Address - Country:US
Practice Address - Phone:516-378-1968
Practice Address - Fax:516-608-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0462151223G0001X
NY0521291223P0700X
NYP82633124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02826084Medicaid
NY01588090Medicaid
NY01627467Medicaid