Provider Demographics
NPI:1073659074
Name:PROFESSIONAL DENTAL OFFICE PC.
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL OFFICE PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:IDALIA
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,
Authorized Official - Phone:212-673-9367
Mailing Address - Street 1:167 RIVINGTON ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-2555
Mailing Address - Country:US
Mailing Address - Phone:212-673-9367
Mailing Address - Fax:212-673-9367
Practice Address - Street 1:167 RIVINGTON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2555
Practice Address - Country:US
Practice Address - Phone:212-673-9367
Practice Address - Fax:212-673-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048431-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty