Provider Demographics
NPI:1114938164
Name:KINGS PLAZA DENTAL PC
Entity Type:Organization
Organization Name:KINGS PLAZA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-258-0011
Mailing Address - Street 1:5412 KINGS PLAZA MALL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-258-0011
Mailing Address - Fax:718-258-1405
Practice Address - Street 1:5412 KINGS PLAZA MALL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:718-258-0011
Practice Address - Fax:718-258-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223G0001X, 1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02683732Medicaid