Provider Demographics
NPI:1073785556
Name:AQUA DENTAL PC
Entity Type:Organization
Organization Name:AQUA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUBINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-788-7888
Mailing Address - Street 1:1283 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2252
Mailing Address - Country:US
Mailing Address - Phone:315-788-7888
Mailing Address - Fax:315-788-7833
Practice Address - Street 1:1283 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2252
Practice Address - Country:US
Practice Address - Phone:315-788-7888
Practice Address - Fax:315-788-7833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0523551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02698960Medicaid
NY1772007OtherUNITED CONCORDIA