Provider Demographics
NPI:1104356476
Name:104 DENTAL, PLLC
Entity Type:Organization
Organization Name:104 DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAKHAEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-476-7801
Mailing Address - Street 1:10423 ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2327
Mailing Address - Country:US
Mailing Address - Phone:718-426-3000
Mailing Address - Fax:718-426-3002
Practice Address - Street 1:10423 ROOSEVELT AVENUE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2327
Practice Address - Country:US
Practice Address - Phone:718-426-3000
Practice Address - Fax:718-426-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0527011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052701Medicaid