Provider Demographics
NPI:1114398807
Name:JACOB A. AVNER, DDS PC
Entity Type:Organization
Organization Name:JACOB A. AVNER, DDS PC
Other - Org Name:GREAT SMILES OF NY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:AVNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-275-7300
Mailing Address - Street 1:9725 64TH AVE
Mailing Address - Street 2:UNIT: G-3
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2236
Mailing Address - Country:US
Mailing Address - Phone:718-275-7300
Mailing Address - Fax:718-275-7307
Practice Address - Street 1:9725 64TH AVE
Practice Address - Street 2:UNIT: G-3
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2236
Practice Address - Country:US
Practice Address - Phone:718-275-7300
Practice Address - Fax:718-275-7307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04968911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02282222Medicaid