Provider Demographics
NPI:1073638151
Name:ROOSEVELT FIELD MALL DENTAL PC
Entity Type:Organization
Organization Name:ROOSEVELT FIELD MALL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIKHAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-294-1919
Mailing Address - Street 1:630 OLD COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-294-1919
Mailing Address - Fax:516-294-6219
Practice Address - Street 1:630 OLD COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-294-1919
Practice Address - Fax:516-294-6219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty