Provider Demographics
NPI:1063630242
Name:YAMAGATA DENTAL, PC
Entity Type:Organization
Organization Name:YAMAGATA DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REN
Authorized Official - Middle Name:
Authorized Official - Last Name:YAMAGATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-867-1188
Mailing Address - Street 1:230 PARK AVE
Mailing Address - Street 2:SUITE 525
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10169-0005
Mailing Address - Country:US
Mailing Address - Phone:212-867-1188
Mailing Address - Fax:
Practice Address - Street 1:230 PARK AVE
Practice Address - Street 2:SUITE 525
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10169-0005
Practice Address - Country:US
Practice Address - Phone:212-867-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0432781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX ID