Provider Demographics
NPI:1073919973
Name:OPEN DOOR FAMILY MEDICAL CENTER SCHOOL BASED MOBILE DENTAL VAN
Entity Type:Organization
Organization Name:OPEN DOOR FAMILY MEDICAL CENTER SCHOOL BASED MOBILE DENTAL VAN
Other - Org Name:OPEN DOOR FAMILY MEDICAL CENTERS, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:914-502-1470
Mailing Address - Street 1:165 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-4702
Mailing Address - Country:US
Mailing Address - Phone:914-937-7817
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST
Practice Address - Street 2:
Practice Address - City:OSSINING
Practice Address - State:NY
Practice Address - Zip Code:10562-4702
Practice Address - Country:US
Practice Address - Phone:914-941-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPEN DOOR FAMILY MEDICAL CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5905200R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)