Provider Demographics
NPI:1093985624
Name:CITYWIDE DENTAL FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:CITYWIDE DENTAL FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-993-7788
Mailing Address - Street 1:384 E 149TH ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3908
Mailing Address - Country:US
Mailing Address - Phone:718-993-7788
Mailing Address - Fax:
Practice Address - Street 1:384 E 149TH ST
Practice Address - Street 2:SUITE 216
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3908
Practice Address - Country:US
Practice Address - Phone:718-993-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02363519Medicaid