Provider Demographics
NPI:1083170021
Name:SOUL DENTAL WEST PLLC
Entity Type:Organization
Organization Name:SOUL DENTAL WEST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALANITCHEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-916-6748
Mailing Address - Street 1:853 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:212-201-0718
Mailing Address - Fax:646-597-6068
Practice Address - Street 1:853 11TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-201-0718
Practice Address - Fax:646-597-6068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055567OtherDENTAL LICENSE