Provider Demographics
NPI:1134118219
Name:CHURCH AVENUE DENTAL P.C.
Entity Type:Organization
Organization Name:CHURCH AVENUE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:TARANOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-941-7275
Mailing Address - Street 1:1113 CHURCH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2803
Mailing Address - Country:US
Mailing Address - Phone:718-941-7275
Mailing Address - Fax:718-532-0917
Practice Address - Street 1:1113 CHURCH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2803
Practice Address - Country:US
Practice Address - Phone:718-941-7275
Practice Address - Fax:718-532-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049110-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty